[Medical Management Alone in Symptomatic Free-Floating Thrombus of the Carotid Artery]

A free-floating thrombus (FFT) is defined as an elongated thrombus attached to the arterial wall with circumferential blood flow distally. This condition accounts for approximately 1.3% of all ischemic stroke cases. Potential causes include hypercoagulable states, pregnancy, inflammatory diseases, malignancies, and atherosclerosis. This study presents a case series and literature review of patients with symptomatic FFT in the carotid artery treated solely with medication.

A series of 4 patients with stroke symptoms and a free-floating thrombus in the carotid artery were treated solely with medical therapy, resulting in no ischemic stroke recurrence within 30 days and complete thrombus resolution.

A literature review of 20 articles encompassing 349 patients with ischemic stroke symptoms and extracranial carotid FFT found that, among the 272 patients treated exclusively with medical therapy, 76 (27.9%) received antiplatelet agents, 146 (53.7%) received anticoagulants, 44 (16.2%) received a combination of both, and 6(2.2%) were treated with intravenous thrombolysis. Recurrent 30-day stroke was experienced by 22 (8.1%) patients. The European Society for Vascular Surgery (ESVS) guidelines recommend anticoagulation therapy for patients with acute stroke secondary to FFT in the carotid artery and suggest considering invasive intervention if recurrence occurs during anticoagulation therapy. The level of evidence is low, and decision-making should be based on factors such as etiology, recurrent events, time since stroke onset, infarct size, thrombus location, and findings from follow-up imaging studies.

Medical treatment alone has shown promising results with low 30-day stroke rates and thrombus dissolution. The limited number of cases and the predominance of retrospective studies or case reports highlight the need for large-scale prospective studies.