What factors would guide your decision to safely resume anticoagulation for atrial fibrillation following a recent intracranial hemorrhage?

Whether a patient with atrial fibrillation and an intracerebral hemorrhage should resume anticoagulation depends on whether the bleed was attributed to cerebral amyloid angiopathy (CAA). Most patients with CAA should not be on long-term (lifelong) anticoagulation. If a bleed was attributed to hypert...

The recent publication of the PRESTIGE-AF study (Veltkamp et al., PMID 40023176) sheds direct light on this question. In 319 patients with ICH of all types (lobar and deep), they report a substantial risk of ICH with any DOAC but a counterbalancing major benefit in stroke prevention.

We also know tha...

We would strongly consider left atrial appendage closure in this situation, with brief anticoagulation after the procedure. It would also depend on the specifics of the anticoagulation; if warfarin, consider a DOAC; if a DOAC, consider switching from rivaroxaban to apixaban.

It is not entirely clear when to restart but I would favor 8 weeks.