DOACs may offer safer stroke prevention after brain bleed

Clinical takeaway: For patients with atrial fibrillation and a history of intracranial hemorrhage, direct oral anticoagulants (DOACs) may provide stroke-prevention benefits without the increased recurrent bleeding risk seen with warfarin, supporting individualized discussions about restarting anticoagulation.

Clinicians often face a difficult tradeoff when managing atrial fibrillation after a brain bleed. While anticoagulation lowers ischemic stroke risk, concerns about triggering another intracranial hemorrhage frequently complicate treatment decisions, and randomized trial data remain limited in this population.

In this nationwide Finnish cohort study, researchers evaluated 1,502 patients (median age, 78 years) with newly diagnosed atrial fibrillation and a previous intracranial hemorrhage that had occurred at least 4 months earlier. Overall, 15% received a DOAC, 29% received warfarin, and 56% received no oral anticoagulant. Participants were followed for up to 2 years.

At 1 year, the adjusted risk of ischemic stroke was less than 1% among DOAC users, compared with 2% among warfarin users and 4% among patients who received no anticoagulation. The risk of recurrent intracranial bleeding was 1% with DOACs, 3% with warfarin, and 2% without anticoagulation. Death from causes other than stroke occurred in 5% of DOAC users, 9% of warfarin users, and 15% of untreated patients.

Compared with no anticoagulation, DOAC use was associated with an 83% lower risk of ischemic stroke and an 80% lower risk of death, without an increased risk of recurrent intracranial bleeding. By contrast, warfarin was associated with a 51% lower risk of ischemic stroke and a 40% lower risk of death, but also an 85% higher risk of another brain bleed.

Investigators also found that warfarin's benefits were concentrated among patients with well-controlled therapy, defined by a time in therapeutic range of at least 70%. Poorer anticoagulation control diminished the apparent protective effect against stroke and death.

“Our findings may help clinicians make more individualized treatment decisions when trying to prevent stroke in people with AFib and prior brain bleeds,” said author Paula Tiili, MD, in a news release.

Source: Tiili P, et al. (2026 Oct 21) Neurology. Anticoagulation in Atrial Fibrillation With Previous Intracranial Bleeding