Background. Oral anticoagulation (OAC) effectively reduces stroke risk in patients with atrial fibrillation (AF), but its use after intracranial hemorrhage (ICH) remains controversial due to bleeding concerns. This study aimed to update the evidence on the efficacy and safety of OAC in AF patients with a history of ICH.

Methods. A systematic review and meta-analysis were conducted according to PRISMA guidelines. We searched PubMed, Scopus, and EMBASE for randomized controlled trials (RCTs) comparing OAC versus avoid anticoagulation in AF patients post-ICH. The primary outcomes were ischemic stroke and recurrent ICH. Secondary outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), major hemorrhage, and a composite endpoint of “net clinical benefit” (first incident ischemic stroke and first incident recurrent ICH). Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results. Four RCTs with 653 participants were included. Anticoagulation was associated with a reduced risk of ischemic stroke (RR 0.23, 95%CI 0.06–0.91) and increased risk of recurrent ICH (RR 3.60, 95%CI 1.40–9.30). No significant differences were observed in all-cause mortality (RR 0.93, 95%CI 0.59-1.46), cardiovascular death (RR 1.01, 95%CI 0.32-3.18) and for net clinical benefit (RR 0.72, 95%CI 0.42-1.24). Anticoagulation was associated with a significant increased risk of any major haemorrhage (RR 2.49, 95%CI 1.29-4.81) and reduced MACE (RR 0.64, 95%CI 0.44-0.94).

Conclusions. Oral anticoagulation in patients with AF and prior ICH was associated with a reduced risk of ischemic stroke and an increased risk of recurrent ICH. PROSPERO code CRD42025637606.