The optimal management of oral anticoagulant (OAC) therapy in atrial fibrillation (AF) patients following intracerebral hemorrhage (ICH) remains uncertain. Although recent randomized controlled trials (RCTs) have investigated this clinical dilemma, findings have been inconclusive.To evaluate the efficacy and safety of restarting OACs in in AF patients after ICH, we conducted a meta-analysis of RCTs.We conducted literature search in PubMed, Embase, and the Cochrane Library (CENTRAL), identifying eligible RCTs from inception to March 2025. The primary outcomes were recurrent ICH and stroke or systemic embolism (SSE). Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model.Three RCTs (APACHE-AF, SoSTART, and PRESTIGE-AF), comprising a total of 623 patients with a median follow-up of 1.2 to 1.9 years, were included. Most patients received direct oral anticoagulants. Compared with non-OAC therapy, OAC resumption was associated with a significantly increased risk of recurrent ICH (RR, 3.32; 95% CI, 1.28-8.61) and major bleeding (RR, 3.33; 95% CI, 1.54-7.22), without a significant reduction in SSE (RR, 0.68; 95% CI, 0.38-1.23). No significant differences were observed in ischemic stroke, major vascular events, all-cause mortality, or cardiovascular mortality.In AF patients with prior ICH, restarting OAC therapy is associated with increased risks of recurrent ICH and major bleeding, without a corresponding reduction in thromboembolic events or all-cause mortality.Copyright © 2025. Published by Elsevier Inc.