Stroke patients are evaluated with a non-contrasted brain computed tomography (CT) scan for decision-making for intravenous thrombolysis. We report a case of a patient who presented with receptive aphasia, and was administered IV alteplase after the non-contrasted brain CT showed no contraindication. However, a dural arteriovenous fistula (dAVF) was detected on the subsequent CT angiography performed in the consideration for endovascular therapy. The patient developed fatal symptomatic intra-cerebral hemorrhage, despite subsequent cessation and reversal of thrombolysis. This case highlights how early CT angiography can be useful in hyper-acute stroke patients beyond the detection of large vessel occlusions, with its ability in revealing stroke mimics such as dural arteriovenous fistula and other contraindications to thrombolysis, which may be missed on the noncontrasted brain CT.