Carotid free-floating thrombus (FFT) is a rare cause of ischemic stroke, usually detected during etiologic vascular studies. There is no consensus regarding the management of carotid free-floating thrombi in those patients.
A 83-year-old male presented to the emergency department with right hemiparesis and dysarthria, consistent with finding of multiple left hemispheric brain infarcts on neuroimaging. Contrast CT showed a free-floating thrombus fixed to an atheroma plaque in left internal carotid artery (ICA). Holter monitorization registered a not previously noticed paroxystic atrial fibrillation. Due to findings, sodic heparinization was started and serial ecosonographic monitoring of the thrombus was performed. He was discharged home with a clot reduction >50% with oral anticoagulant therapy (rivaroxaban 20mg daily). At 2 months, ecographic control was realized without residual clot in left ICA.
Oral anticoagulation is currently the first therapeutic option that should be considered when a FFT is detected. In some reported case series, simple antiplatelet therapy was associated. Deferred surgical endarterectomy has a limited therapeutic gap in these patients when an ulcerated atheroma plaque or a significant stenosis carotid stenosis are detected. Surgical thrombectomy is reported only in few cases series. Endovascular therapies are steadily growing as an effective option when a FFT is detected, usually associated with distal protection devices to avoid distal embolization.
