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

Abstract

Background: There is no consensus regarding the management of carotid free-floating thrombi in patients with acute ischemic stroke and transient ischemic attack. Aims: 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. Methods: 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). Summary of review: 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. Conclusions: 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 freefloating thrombi.

Carotid Stenting as Definitive Treatment for Free Floating Thrombus—Review of 7 Cases

“…From a medical perspective the principle treatment options consist of anti-coagulation, anti-platelet therapy or thrombolysis. In the recent systematic literature review of Fridman et al [10]. The primary endpoint in this analysis was a composite of any stroke, transient ischemic attack (TIA), silent brain ischemia on diffusion-weighted MRI scan, or death at 30 days after the index event.…”

Clinical implications of the incidental finding of a free‐floating thrombus in the internal carotid artery

“…FFT constitute a rare, but known, cause of cerebral ischemia. The prevalence of FFT is described at about 1.5% to 1.6% in stroke or transient ischemic attack (TIA) patients . Carotid artery ultrasonography is not only of importance for a first diagnosis, but furthermore provides an ideal monitoring method .…”

“…The prevalence of FFT is described at about 1.5% to 1.6% in stroke or transient ischemic attack (TIA) patients . Carotid artery ultrasonography is not only of importance for a first diagnosis, but furthermore provides an ideal monitoring method . Regarding the prognosis, Fridman et al found a 17.1% risk of TIA, silent brain ischemia, stroke, or death in a 30‐day follow‐up of patients admitted to hospital for acute ischemic stroke.…”

“…Despite this high short‐term morbidity and mortality, a therapeutic gold standard has not been established: There are several studies, including a recent prospective work and a meta‐analysis, as well as case reports on medical, surgical, and interventional approaches without a clear superiority regarding the clinical outcome. Inter alia, there are reports of different types of antiplatelet therapy including aspirin, clopidogrel, and ticlopidine, anticoagulation by either heparin, enoxaparin, dalteparin, or warfarin, off‐label uses of dabigatran or apixaban, surgical thrombectomy, and interventional stent‐retriever maneuvers (Table ). Based on the infrequency of description, none of these studies particularly addresses incidental findings but rather focus on symptomatic patients admitted to hospital for stroke or TIA.…”

“…Few data are available on the natural course of an FFT . Besides detachment with distal embolization, a spontaneous re‐adhesion or resolution have been discussed in the literature .…”