Carotid Free-floating Thrombus Research Articles

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63%) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p<0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6%, respectively; p=0.1) and at latest follow-up (70.8 vs 50%; p=0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6% vs 13.5%; p=0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2%; p<0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0%; p=0.1, respectively). Sensitivity analysis comparing exclusive ACT vs Dual APT lead to similar results. Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Abstract WMP10: Carotid Floating Thrombus; Medical Management and Outcomes

Background: Carotid free-floating-thrombus(CFT)is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by contrast. Unfortunately, there is no clear consensus among experts on the ideal treatment for CFT. Methods: Retrospective analysis of acute ischemic stroke(AIS)patients diagnosed with internal carotid CFT on CTA between January2015-March2023.We aimed to compare two treatment regimens: antiplatelet(APT) and anticoagulation(ACT) in the treatment of CFT. APT regimens included the use of dual or single APT (aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin+/-aspirin. Patients that underwent thrombectomy were excluded. Results: During study time there were 8252 AIS patients, of which 137(1.6%) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.4years + 12.8;p&lt;0.01) (Table 1) .Other demographic variables were similar between groups. Complete CFT resolution by repeat imaging was comparable between groups at 30 days (58.8vs31.6%;p=0.1) and at latest follow-up (70.8vs50%;p=0.1) on ACT vs APT, respectively. There were similar rates of any ICH (13.5vs27.6%;p=0.5), PH1/2, independence at discharge and similar hospital length of stay between APT and ACT groups, respectively ( Table 1 ). Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5vs55.2%;p&lt;0.001).The rate of recurrent AIS was comparable among APT and ACT at 30 days (0vs3.4%;p=0.1,respectively).Sensitivity analysis comparing DAPT to exclusive ACT lead to similar results. Conclusion: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed with APT vs ACT. Larger prospective studies are needed.

Symptomatic Carotid Free-Floating Thrombus: About Management of 50 Cases in a Referral Neurovascular Center

Background: Carotid free-floating thrombus (CFFT) is an uncommon disorder. The aim of this study was to describe a French cohort of CFFT patients. Methods: We conducted a retrospective monocentric study from a Stroke Center among patients admitted for stroke with CFFT. Results: Between January 2017 to December 2019, 2038 ischemic strokes were recorded. A total of 50 patients with CFFT were consecutively included (32 men/18 women). The mean age was 58.2 years (±11.7). Their etiologies were atheroma (46%), carotid dissection and web (20%), hypercoagulability disorders (16%) and arrhythmia (10%). Exclusive medical management was performed in 38 patients (76%): 29 (59.2%) were anticoagulated and 9 (18.4%) received antiplatelets alone in the first week. Surgical intervention was performed in the first 30 days for 11 patients (22%). The main surgical indication was a residual carotid stenosis over 70%. Only three patients had a recurrent stroke in the medical group with anticoagulants. No patients in the antiplatelet group or the surgical group had a recurrent stroke. Conclusions: Our study summarized a large cohort of 50 patients with CFFT. This diagnosis implies the need to search for a local arterial disease and to screen for hypercoagulability states. An initial medical strategy followed by a delayed carotid surgery if the follow-up imaging shows a residual stenosis appears to be safe.

Carotid free-floating thrombus stemming from carotid web: co-occurrence of two rare causes of ischemic stroke

BackgroundCarotid web (CaW) and carotid free-floating thrombus (CFFT) are rare yet critical causes of ischemic stroke in young adults.Case presentationA 54-year-old woman presented with a fluctuating right sensory-motor faciobrachial syndrome. A brain MRI scan revealed multiple small recent asynchronous cortico-subcortical ischemic foci in the vascular territory of the left internal carotid artery. A CT angiography identified a CFFT in the left internal carotid artery arising from an underlying CaW. The patient was treated with excellent clinical outcomes with carotid artery stenting and dual antiplatelet therapy.ConclusionsWe provide a structured pathophysiological rationale connecting CaW and CFFT and highlight pivotal therapeutic implications. Further studies are needed to investigate this relationship and guide assessment and treatment.

Carotid free-floating thrombus revealed by optical coherence tomography.

Carotid free-floating thrombus revealed by optical coherence tomography.

Endovascular Thrombectomy for a Progressive Stroke Patient With a High-Burden Carotid Free-Floating Thrombus.

Carotid free-floating thrombus (FFT) is a rare cause of acute ischemic events. The optimal management of carotid FFT remains unclear. The optimal and individualized management of carotid FFT should be determined based on the underlying etiology, clinical manifestation, and imaging characteristics. we reported a case with endovascular thrombectomy for a progressive stroke patient with a high-burden carotid free-floating thrombus. ANN NEUROL 2024;95:362-364.

A Free-Floating Internal Carotid Artery Thrombus and Acute Ischemic Stroke

Acute management of stroke with carotid free-floating thrombus (FFT) needs careful monitoring to proactively prevent the additional risk of infarction, and reducing intracranial bleeding is the primary goal. No management guidelines are available for this rare clinical condition. Here we presented a case study of a patient presenting with a carotid FFT with acute left-sided weakness. The patient was managed with anticoagulation alone, and the patient was discharged to return home in stable condition and good functional status with mild disability in the patient's left arm. In conclusion, carotid FFT is a rare clinical condition with underlying heterogeneous etiologies and individual-level bleeding risk stratification. Medical and surgical options are considered on a case-by-case basis.

Carotid free-floating thrombus in COVID-19: a cerebrovascular disorder of cytokine storm-related immunothrombosis.

Several neurological manifestations, including stroke, have been reported in COVID-19 patients. The putative role of the COVID-19-related hyperinflammatory state in cerebrovascular disorders remains unclear. From March 2020 to September 2021, we searched for patients who exhibited an ischemic stroke related to carotid free-floating thrombus (CFFT) to investigate its incidence and relationship with COVID-19. Of 853 ischemic strokes referred to our Stroke Centre during the study period, 5.7% (n = 49) were positive for SARS-CoV-2. Six had CFFT, of which two tested positive for SARS-CoV-2 (2/49 = 4.1%), and four did not (4/802 = 0.5%). The former were two middle-aged men suffering from COVID-19 pneumonia. Floating thrombi were promptly extracted by endarterectomy and endovascular thrombectomy, respectively, with no early and long-term complications. Notably, our COVID-19 patients exhibited little or no atherosclerosis burden on CT angiography, markedly elevated D-dimer levels, and extensive thrombus length. COVID-19-induced immunothrombosis possibly played a significant pathogenic role in CFFT.

Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort

BackgroundCarotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture,...

Carotid free-floating thrombus during COVID-19 vaccine era: causality or not?

Carotid free-floating thrombus (FFT) is very rarely diagnosed in patients with acute ischemic stroke. It is a real clinical emergency due to the significant risk of death associated with thromboembolic complications. Herein, we present three patients with ischemic stroke caused by carotid FFT after less than 20 days from administration of mRNA vaccine BNT162b1 (Pfizer/BioNTech) for Severe Acute Respiratory Syndrome—CoronaVirus 2 (SARS-CoV-2). To our knowledge, these are the first cases reporting carotid FTT following SARS-CoV-2 vaccination.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10072-022-06307-1.

A Case of Carotid Free-floating Thrombus Caused by Stenosis of the Brachiocephalic Artery with Subclavian Double Steal Phenomenon

A Case of Carotid Free-floating Thrombus Caused by Stenosis of the Brachiocephalic Artery with Subclavian Double Steal Phenomenon

Differentiating Carotid Free-Floating Thrombus From Atheromatous Plaque Using Intraluminal Filling Defect Length on CTA: A Validation Study.

To validate a previously proposed filling defect length threshold of >3.8 mm on CT angiography (CTA) to discriminate between free-floating thrombus (FFT) and plaque of atheroma. This was a prospective multicenter observational study of 100 participants presenting with TIA/stroke symptoms and a carotid intraluminal filling defect on initial CTA. Follow-up CTA was obtained within 1 week and at weeks 2 and 4 if the intraluminal filling defect was unchanged in length. Resolution or decreased length was diagnostic of FFT, whereas its static appearance after 4 weeks was indicative of plaque. Diagnostic accuracy of FFT length was assessed by receiver operating characteristic analysis. Ninety-five participants (mean [SD] age 68 [13] years, 61 men, 83 participants with FFT, 12 participants with a plaque) were evaluated. The >3.8-mm threshold had a sensitivity of 88% (73 of 83) (95% confidence interval [CI] 78%-94%) and specificity of 83% (10 of 12) (95% CI 51%-97%) (area under the curve 0.91, p < 0.001) for the diagnosis of FFT. The optimal length threshold was >3.64 mm with a sensitivity of 89% (74 of 83) (95% CI 80%-95%) and specificity of 83% (10 of 12) (95% CI 51%-97%). Adjusted logistic regression showed that every 1-mm increase in intraluminal filling defect length is associated with an increase in odds of FFT of 4.6 (95% CI 1.9-11.1, p = 0.01). CTA enables accurate differentiation of FFT vs plaque using craniocaudal length thresholds. ClinicalTrials.gov Identifier: NCT02405845. This study provides Class I evidence that in patients with TIA/stroke symptoms, the presence of CTA-identified filling defects of lengths >3.8 mm accurately discriminates FFT from atheromatous plaque.

Carotid free-floating thrombus treated with apixaban: report of a case and review of literature

Carotid free-floating thrombus treated with apixaban: report of a case and review of literature

Diagnosis and Management of Carotid Free-Floating Thrombus: A Systematic Literature Review

BackgroundThere is no consensus regarding the management of carotid free-floating thrombi in patients with acute ischemic stroke and transient ischemic attack.AimsThis systematic review aims to (1)...

Diagnosis and management of carotid free-floating thrombus: A systematic literature review.

There is no consensus regarding the management of carotid free-floating thrombi in patients with acute ischemic stroke and transient ischemic attack. This systematic review aims to (1) describe the current imaging methods for diagnosis of carotid free-floating thrombi and its associated risk factors, (2) estimate the proportion of carotid free-floating thrombi diagnosed in stroke patients, (3) estimate the proportion of carotid free-floating thrombi patients treated medically and surgically, and (4) evaluate 30-day outcomes. We searched MEDLINE, EMBASE, and manually for references reporting carotid free-floating thrombi from 1960 until June 2017. We estimated the frequency of carotid free-floating thrombi and evaluated 30-day outcomes using Cox regression. We defined the timing of surgical intervention as early (less than 72 h) and delayed (more or equal to 72 h). We retrieved 525 carotid free-floating thrombi cases from 58 case series and 83 case reports. Carotid free-floating thrombi were present in 1.53% of stroke patients. Carotid free-floating thrombi diagnosis was made by digital subtraction angiography (38.1%), carotid duplex ultrasound (29.5%), and computed tomography angiography (29.5%). The 30-day risk of transient ischemic attack, silent brain ischemia, any stroke or death was 17.1%. In multivariate analyses, there were no differences in outcome for any anticoagulation regime or timing of revascularization procedure. The diagnosis of carotid free-floating thrombi is more common due to the increased use of early noninvasive vascular imaging in transient ischemic attack and stroke. It poses a high short-term risk of stroke and death, but there is as yet no established treatment. The low quality of evidence in the carotid free-floating thrombi literature limits the interpretation of our results and warrants a large-scale prospective cohort study in carotid free-floating thrombi.

A Case of Carotid Free-floating Thrombus Longitudinally Extending to the Craniocervical Junction after Intravenous Thrombolytic Therapy for Acute Internal Carotid Artery Occlusion

A Case of Carotid Free-floating Thrombus Longitudinally Extending to the Craniocervical Junction after Intravenous Thrombolytic Therapy for Acute Internal Carotid Artery Occlusion

Recurrent Ischemic Stroke by Carotid Free-Floating Thrombus in Patient with Antiphospholipid Antibody Syndrome

Carotid free-floating thrombus (FFT) is a rare cause of stroke. The FFT is commonly associated with an atherosclerotic plaque rupture, but other causes need to be examined in young patients. We report a case of 31-year-old male patient with recurrent ischemic stroke caused by carotid FFT. Although initial laboratory test was unremarkable, recurrent stroke events led us to perform additional study and antiphospholipid syndrome (APLS) was diagnosed. Repetitive testing for APLS seems considerable when young patients present with recurrent stroke. Key Words: Stroke, Thrombosis, Antiphospholipid syndrome

Abstract TP117: A Systematic Literature Review of Patients With Carotid Free Floating Thrombus and Acute Ischemic Stroke

Introduction: Carotid Free Floating Thrombus (CFFT) includes numerous pathological entities. It is theorized that CFFT leads to ischemic stroke secondary to embolization with high risk of short-term recurrence. There is uncertainty in diagnosis, prognosis, and optimal medical or surgical management of CFFT. To synthesize the vast recent literature, we performed a systematic literature review (SLR) of CFFT. Methods: Literature search for Thrombus, Carotid and related terms yielded 3126 results. After a preliminary assessment of 3126 retrieved manuscripts, 273 were reviewed in detail. A total of 144 manuscripts met entry criteria. We present the demographics, risk factors (RF), treatment modality and outcome of stroke or death at 30 days of CFFT patients. Acute treatment modalities consisted of surgical (carotid endarterectomy or stenting within 72 hours) or medical interventions. The relationship between treatment modality and outcome was assessed using logistic regression including relevant RF, antithrombotic type, demographic, imaging, and surgical variables. Results: Our SLR yielded 530 CFFT patients with a median age at presentation of 60.5 (IQR 48-71) and 36.2% were females. The majority (64%) of patients had at least one RF. Patients were treated acutely surgically (27.9%) or medically (82.7% with anticoagulation, 16.8% with dual antiplatelet (DA). Thirty-day stroke and death rate was 17.1% in 345 cases with follow-up. Patients receiving dual antiplatelet therapy had an increased risk of stroke or death at 30 days (RRR 30.31, 95% confidence interval, 1.66- 553.22; P =0.02) compared to patients not receiving dual antiplatelet therapy. There was no significant relationship between early anticoagulation or acute surgical approach and primary outcome, although a trend favoring anticoagulation over surgical approach was seen (13.6% vs. 21.9%). Conclusions: CFFT patients are at a short-term high risk for stroke or death. DA was associated with increased short term risk in these patients; however, the optimal treatment approach remains uncertain. Future studies are needed as RCTs are lacking and publication bias limits our findings.

Intra-operative detection of carotid free-floating thrombus in a symptomatic patient with a methylenetetrahydrofolate reductase gene mutation. Case report and literature review

Intra-operative detection of carotid free-floating thrombus in a symptomatic patient with a methylenetetrahydrofolate reductase gene mutation. Case report and literature review

Diagnosis and Surgical Management of Free-Floating Thrombus Within the Carotid Artery

Free-floating thrombus (FFT) of the carotid artery is a rare condition of currently unknown etiology. Less than 150 cases have been described in the published world literature to date. We present 6 consecutive cases of carotid FFT, identified prospectively from 5000 carotid duplex scans over a 34-month period in a single tertiary center for vascular surgery. All 6 cases involved the left carotid bifurcation in neurologically symptomatic individuals. In 5 of the 6 cases, FFT occurred in the absence of a significantly stenosing atheromatous plaque and was not associated with an elevation in velocity on duplex. The patients were all treated with surgical thromboendarterectomy, with good result. Duplex imaging can underestimate the degree of stenosis. Free-floating thrombus presents a challenge in diagnosis due to its rapidly evolving nature. The management of FFT by acute thromboendarterectomy appears to be safe and effective in limiting further focal neurological sequelae.