Carotid Free-Floating Thrombus: A Case Series, Narrative Review, and Proposal for Biology-Guided Treatment Selection

Background: Carotid free-floating thrombus (CFFT) is an uncommon but clinically significant cause of transient ischemic attack and ischemic stroke, carrying a substantial risk of recurrent cerebral embolization. Despite advances in vascular imaging, the optimal management of CFFT remains controversial because available recommendations are largely based on retrospective studies, case series, and expert opinion. The present study reports a single-center experience with CFFT and provides an updated narrative review of current diagnostic and therapeutic strategies, with particular attention to the timing of intervention. Methods: A retrospective review of patients diagnosed with CFFT and managed at our institution over a 20-year period was performed. Clinical presentation, imaging findings, treatment strategy, and outcomes were analyzed. In parallel, a narrative review of the contemporary literature was conducted to summarize current evidence regarding medical management, carotid endarterectomy, endovascular techniques, hybrid approaches, and emerging concepts related to thrombus composition and maturation. Results: Five patients with symptomatic CFFT were identified. Four patients underwent carotid thromboendarterectomy, whereas one patient was managed medically with anticoagulation and antiplatelet therapy, resulting in complete thrombus resolution. Two patients experienced neurological deterioration while receiving initial anticoagulation and subsequently required urgent surgical intervention. No postoperative strokes occurred after carotid endarterectomy. Review of the literature confirmed that anticoagulation remains the cornerstone of initial therapy and achieves thrombus resolution in a substantial proportion of patients. However, recurrent neurological events continue to occur under medical treatment, while the indications and timing of invasive intervention remain poorly defined. Recent advances in high-resolution magnetic resonance imaging and optical coherence tomography suggest that thrombus age and composition may become important determinants of future treatment selection. Conclusions: CFFT represents a rare but potentially unstable vascular condition for which high-quality evidence is still lacking. Initial anticoagulation remains the most widely accepted treatment strategy, while carotid endarterectomy, endovascular thrombectomy, carotid artery stenting, and hybrid procedures may be appropriate in selected patients. Future management algorithms may ultimately move beyond a one-size-fits-all approach by incorporating thrombus biology, imaging characteristics, and individual patient risk profiles. Although this concept remains preliminary, advances in thrombus characterization may provide the foundation for more personalized treatment strategies as further clinical evidence becomes available.