© 2014 The Authors. Published by Elsevier B.V. Objectives Atrial fibrillation is closely associated with cardioembolic stroke. Until recently, warfarin has been the gold standard for the treatment of atrial fibrillation. Since 2010 the United States Food and Drug Administration has approved three new agents for anticoagulation in patients with atrial fibrillation. The purpose of this case report is to discuss some of the practical implications for using these agents. Methods A patient taking apixaban presented with a spontaneous cerebellar hemorrhage. While the patient was initially considered a candidate for surgical intervention, the lack of literature addressing surgical intervention in patients on novel anticoagulation clouded the clinical decision-making. The patient was ultimately managed with administration of activated prothrombin complex concentrate, blood pressure control, frequent clinical assessments and airway protection. The patient did not undergo craniotomy for hematoma evacuation. Conclusions Recent FDA approval of several novel oral anticoagulants for use in patients with atrial fibrillation has resulted in a significant number of patients formerly treated with warfarin being switched to these newer agents. There remains a lack of clear guidelines for the management of hemorrhagic complications. This case report describes one management strategy and highlights the paucity of current evidence to support critical clinical decisions.