Oral anticoagulation versus no anticoagulation after spontaneous intracranial hemorrhage in patients with atrial fibrillation: a systematic review and meta- analysis of randomized controlled trials

The decision to resume oral anticoagulation (OAC) in patients with atrial fibrillation (AF) after an intracranial hemorrhage (ICH) remains a significant clinical challenge due to competing risks of ischemic stroke and recurrent bleeding. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing long-term OAC with no OAC in patients with AF following an ICH. We searched MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov through September 2025. The primary outcomes were ischemic stroke and ICH. Secondary outcomes included major adverse cardiovascular events (MACE), major bleeding, cardiovascular mortality, and all-cause mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Five RCTs were included. Compared to no anticoagulation, restarting OAC significantly reduced the risk of ischemic stroke (RR 0.20; 95% CI: 0.05–0.75) and MACE (RR 0.59; 95% CI: 0.37–0.94). However, it was associated with increased risks of ICH (RR 3.51; 95% CI: 1.50–8.22) and major bleeding (RR 2.22; 95% CI: 1.06–4.62). There were no significant differences in cardiovascular mortality (RR 1.00; 95% CI: 0.44–2.28) or all-cause mortality (RR 0.94; 95% CI: 0.65–1.37). In patients with AF who have survived an ICH, resuming OAC appears to significantly reduce the risks of ischemic stroke and MACE, but increases the likelihood of bleeding. No survival benefit was observed. Future RCTs are needed to define the optimal timing of OAC initiation after ICH and the subpopulations most likely to benefit from this treatment strategy.