Cerebral haemorrhage in anticoagulated patients with mechanical valvular prosthesis poses an uncommon but difficult management problem. Four such patients are presented: one patient had delayed haemorrhagic transformation of a preexisting cerebral infarct, one probably had de novo haemorrhage complicating hypertension and in two patients cerebral haemorrhage was associated with excessive anticoagulation. Conservative management including the use of fresh frozen plasma, delayed heparinisation and warfarinisation was used. Both patients with anticoagulant overdose died as a result of extensive haemorrhage despite the drainage of cerebellar haematoma in one patient. The remaining two patients survived with minimal neurological deficits. Diagnosis of the underlying cause of cerebral haemorrhage, and the timing of heparinisation and anticoagulation are discussed.