TOPLINE:

In patients with atrial fibrillation (AF) and a history of intracerebral haemorrhage (ICH), restarting oral anticoagulants significantly reduced the risk for ischaemic stroke and major adverse cardiovascular events (MACE) but increased the risk for recurrent ICH and major haemorrhage. No differences were observed in all-cause mortality or cardiovascular death.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis of six randomised controlled trials identified from various databases to assess the efficacy and safety of restarting oral anticoagulants vs avoiding anticoagulants in patients with AF and a history of spontaneous ICH.
• A total of 798 patients were included and stratified into treatment groups: 403 initiated oral anticoagulants (mean age, 78.5 years; 37% women) and 395 avoided anticoagulants (mean age, 78.2 years; 37% women).
• The primary efficacy outcome was the occurrence of a new ischaemic stroke; the secondary efficacy outcome was ischaemic MACE (a composite of ischaemic stroke, systemic arterial embolism, pulmonary embolism, and myocardial infarction).
• The primary safety outcome was recurrent ICH, and secondary safety outcomes included haemorrhagic MACE, all-cause mortality at follow-up, and cardiovascular death.

TAKEAWAY:

• Patients who initiated anticoagulants had an 80% lower risk for a new ischaemic stroke (risk ratio [RR], 0.20; number needed to treat = 9, ie, one stroke prevented per nine patients treated), and a 59% lower risk for ischaemic MACE (RR, 0.41) than those who did not receive anticoagulants (P < .05 for both).
• Those who initiated anticoagulants had an approximately threefold higher risk for recurrent ICH, with an estimated number needed to harm of 19 (ie, one additional brain bleed occurs for every 19 patients treated) and about a twofold higher risk for haemorrhagic MACE than those who did not receive anticoagulants (P < .05 for both).
• The risks for all-cause mortality and cardiovascular death did not differ significantly between the two groups.

IN PRACTICE:

"Our findings suggest that resuming oral anticoagulation after ICH may provide net benefit in appropriately selected patients with AF, primarily through the prevention of ischaemic stroke and other thromboembolic events. However, the decision to restart should be individualised, taking into account the underlying ICH phenotype (lobar vs non-lobar), baseline haemorrhagic risk, comorbidities, and the patient's competing ischaemic risk profile," the authors wrote.

SOURCE:

This study was led by Nikolaos M. Papageorgiou, Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. It was published online on December 21, 2025, in Therapeutic Advances in Neurological Disorders.

LIMITATIONS:

The study included a small number of trials with modest sample sizes, resulting in imprecise estimates and wide prediction intervals. Variability in study design and follow-up duration contributed to heterogeneity. Follow-up duration varied substantially across studies, ranging from approximately 6 to 24 months, which may have influenced outcome comparability.

DISCLOSURES:

This study did not receive any specific funding. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.