Free-Floating Thrombus in Stroke: Therapeutic Dilemmas and Case Series Analysis

Free-floating thrombus (FFT) is a rare but clinically significant vascular finding, not only in ischemic stroke but also in other contexts such as routine imaging for asymptomatic patients or evaluation of other vascular diseases. It is characterized by an intraluminal thrombus adherent to the arterial wall with partial luminal occlusion and cyclic movement synchronized with the cardiac cycle. Although associated with an increased risk of embolic complications, including recurrence, no consensus exists regarding optimal management. This study aims to describe the clinical and radiological characteristics of FFTs in a hospital-based case series and to report treatment strategies and outcomes.

A retrospective study was conducted over a 17-month period (2023-2024) at Ibn Rochd University Hospital, including patients with acute ischemic stroke and FFT diagnosed via computed tomography angiography (CTA) and/or duplex ultrasound (DUS). Collected data included age, NIHSS score at admission, etiological workup, and both clinical and imaging outcomes. Therapeutic management was guided by stroke severity, hemorrhagic risk, availability of treatment modalities, and the results of the etiological workup.

Among 940 ischemic stroke cases, FFT was identified in eight patients (0.8%), with a mean age of 50.6 years. Atherosclerosis was the predominant etiology. The thrombus was most frequently localized in the carotid arteries, but also involved the brachiocephalic and vertebral arteries. No patients received intravenous thrombolysis due to concerns regarding embolization risk. Medical management was applied in all cases, with six patients receiving anticoagulation therapy, and five of them receiving combined antiplatelet therapy and statins. One patient underwent delayed carotid endarterectomy following stroke recurrence. At three months, thrombus resolution was complete in four cases, while the remaining patients exhibited partial regression.

FFT represents a high-risk entity for stroke recurrence, requiring individualized management. In our limited case series, medical management (primarily anticoagulation, sometimes combined with antiplatelet therapy) was observed to be associated with thrombus resolution in most patients. Delayed surgical or endovascular intervention may be considered in cases of persistent thrombus or recurrence. These observations should be interpreted with caution. Larger prospective studies are needed to define optimal management strategies and clarify the role of endovascular interventions.