Acute cerebral infarction is a common neurological emergency associated with high morbidity and mortality. Management becomes particularly challenging in patients with decompensated liver cirrhosis, who frequently present with coagulopathy and thrombocytopenia, thereby carrying simultaneous risks of hemorrhage and thrombosis. These competing clinical risks substantially complicate antiplatelet treatment decisions. We report a case of acute right brainstem infarction in a patient with hepatitis B– related decompensated liver cirrhosis, prior transjugular intrahepatic portosystemic shunt (TIPS) placement, coagulopathy, and progressive thrombocytopenia. Owing to the patient’s markedly elevated bleeding risk, antiplatelet therapy was initially withheld. Conservative management was undertaken, including plasma transfusion to improve coagulation status, acid suppression and gastric mucosal protection, and maintenance of cerebral perfusion, accompanied by close dynamic monitoring of coagulation parameters and platelet counts. This case highlights the complexities of individualized clinical decision-making in patients with acute cerebral infarction complicated by advanced liver disease and severe hematological abnormalities. It further underscores the importance of balancing thrombotic and hemorrhagic risks in developing safe and effective management strategies for this highly vulnerable patient population.