In contrast, recent real-world observational studies (including some very large registry datasets) from ICH survivors with AF suggest that anticoagulation might reduce mortality and ischemic complications, without an unacceptable increase in ICH. A recent systematic review and meta-analysis of observational studies suggested that restarting anticoagulation was associated with a signi cantly lower risk of thromboembolic complications (pooled RR, 0.34; 95% CI, 0.25-0.45; Q 5.12; P for heterogeneity .28) with no increased risk of recurrent ICH (pooled RR, 1.01; 95% CI, 0.58-1.77; Q 24.68; P for heterogeneity < However, none of the real-world studies strati ed ICH by location, nor by CMB burden or distribution. Two small randomized studies of early anticoagulation after ICH were not able to con rm bene t There are no reliable randomized trial data to guide the timing of anticoagulation after ICH. In acute ICH, hematoma expansion is common and is aggravated by anticoagulation. Anticoagulants should therefore be reversed and avoided in acute ICH (< 24-48 h). A survival model based on observational data indicated that the total stroke risk (both ischemic and ICH) was lowest when anticoagulation was restarted after about 10 weeks, and a delay of at least 4 weeks after ICH was There are no large-scale RCTs to answer the question of whether long-term anticoagulation has net bene t in ICH survivors with AF. NOACs have an approximately 50% lower ICH risk than VKA124 and are therefore preferred in most ICH survivors, except where warfarin is indicated (eg, in those with metallic mechanical heart valves). 