Hindawi Publishing Corporation

Case Reports in Medicine

Volume 2017, Article ID 4932567, 4 pages
http://dx.doi.org/10.1155/2017/4932567

Case Report
Free Floating Thrombus in Carotid Artery in
a Patient with Recurrent Strokes

Moni Roy,1 Ashish Kumar Roy,1 Jeffrey R. DeSanto,1 and Murad Abdelsalam2
1
Department of Internal Medicine, University of Illinois College of Medicine, OSF Saint Francis Medical Center,
530 NE Glen Oak Avenue, Peoria, IL, USA
2
Department of Cardiology, St. Joseph Mercy Oakland Hospital, 44405 Woodward Avenue, Pontiac, MI, USA

Correspondence should be addressed to Moni Roy; moni.roy@osfhealthcare.org

Received 22 October 2016; Accepted 18 December 2016; Published 10 January 2017

Academic Editor: Aristomenis K. Exadaktylos

Copyright © 2017 Moni Roy et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting
with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop
and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis
along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our
case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without
recurrence of TIAs or strokes on six-month follow-up.

1. Introduction facility included echocardiogram, which was normal. Cardiac

telemetry monitoring revealed no arrhythmia. Prior carotid
Free floating thrombus (FFT) in the carotid artery is an duplex from four years ago showed less than 50% stenosis
uncommon finding and rarely reported in the literature [1]. of both carotid arteries and no repeat carotid duplex was
The treatment options for these patients include medical done on admission. During his hospital stay, the right sided
management or surgical interventions, both of which have hemiplegia showed significant improvement on the next
been reported to have similar outcomes [2]. day of admission. However, on day three of hospitalization,
he had an acute worsening of his right sided weakness.
2. Case Presentation Stroke alert was called and emergent computed tomography
angiography (CTA) of head and neck was ordered. CTA
A 72-year-old Caucasian male with past medical history of imaging showed 90% stenosis of proximal left internal carotid
coronary artery disease, diabetes mellitus, hypertension, and artery (ICA) with free floating thrombus (FFT) within the
hyperlipidemia was transferred to our facility with acute lumen along with adjacent calcified atheromatous plaque.
right sided facial droop and dysarthria. Initially, patient Left paramedian pons hypodensity consistent with acute
experienced gradual onset right lower extremity weakness ischemia was a new finding. Occlusion of right vertebral
followed by slurring of speech. Over the next day his artery at origin with collaterals from occipital artery and
symptoms progressed to right sided hemiplegia, dysarthria, occluded posterior inferior cerebellar artery (PICA) were
and behavioral disturbances with emotional liability. Family noted (Figures 1–3).
reported history of cerebrovascular accidents in the past
with no residual symptoms. Magnetic resonance imaging 3. Treatment
(MRI) done at outlying hospital showed old infarcts in right
cerebellum, left parietal lobe, left thalamus, bilateral occipital Patient was transferred to neurology intensive care unit and
lobes, and bilateral basal ganglia. Further workup at our was started on heparin drip. Neurosurgery and vascular
2 Case Reports in Medicine

Figure 1: Coronal reformatted view from CT angiogram shows an Figure 3: Sagittal oblique reformatted view from CT angiogram
intraluminal filling defect within the proximal left internal carotid again depicts the intraluminal thrombus within the left internal
artery consistent with thrombus (white arrow). There is also adjacent carotid artery (white arrow).
calcified atheromatous plaque (black asterisk). The internal carotid
arteries are tortuous and deviate medially into the retropharyngeal
space. 5. Discussion
Free floating thrombus is an uncommon entity with variable
reported incidence depending on method of imaging used.
Incidence has been reported to be as low as 0.05% in a
retrospective study with ultrasonography used for carotid
artery imaging [1]. On the other hand, Buchan et al. detected
FFT in 1.45% (29/2,000) angiograms of patients with high- or
moderate-grade ICA stenosis [3].
There are multiple and diverse causes of carotid FFT
formation. Atherosclerosis has been reported to be the most
common etiology. Carotid stenosis in itself with altered blood
flow around the area of stenosis would cause increased risk
of FFT. As per our literature review, no direct correlation
between the degree of preexisting stenosis and risk of FFT
has been reported. Our patient had a carotid ultrasound four
years ago with less than 50% stenosis in bilateral carotid
arteries, classified as mild stenosis per North American
Symptomatic Carotid Endarterectomy Trial (NASCET) [4].
Figure 2: Axial image from CT angiogram demonstrates free Our patient had a progression of stenosis from less than 50%
floating thrombus within the internal carotid artery lumen “donut to 90% over 4-year period. Smaller studies have been done to
sign” (white arrow).
evaluate the progression of carotid stenosis over years, though
no clear recommendations on surveillance exist. Johnson
et al., in study of 232 patients with less than 80% stenosis,
reported that 23% over 10 years progressed to severe stenosis
surgery services were consulted. After discussions with
(defined as 80–99%) [5]. Park et al. studied the natural
patient and family; medical management was decided with
history of asymptomatic moderate carotid artery stenosis and
both anticoagulation and antiplatelet therapy. He was started
reported 32% of cases progressed to severe stenosis but only
on Aspirin and Warfarin with international normalized
97% became symptomatic [6].
ration (INR) target of 2-3.
FFT usually presents with acute neurological deficit.
Bhatti et al. reported 92% of cases with neurological symp-
4. Outcome and Follow-Up toms and 4% were asymptomatic [2]. Similar results were
reported by Ferrero et al. where 14 out of 16 cases over
Patient was transferred to inpatient stroke rehabilitation unit a period of 9 years were symptomatic [7]. Our patient
for three weeks of occupational and physical therapy. He later was symptomatic at time of presentation with neurological
was safely discharged home on Aspirin and Warfarin for long deficits. Also his reported history of TIAs prior to admission
term anticoagulation. At six months of follow-up, patient did was likely clinical manifestation of developing FFT.
not have recurrence of any neurological deficits and showed Different imaging modalities have been used to diagnose
good residual motor function. FFT. Ferrero et al. in a single center study reported that
Case Reports in Medicine 3

duplex scan and digital subtraction angiography (DSA) had (4) No direct correlation between the degree of preexist-
sensitivity of 62.5% and 100%, respectively [7]. The current ing carotid artery stenosis and risk of FFT has been
American Heart Association for acute neurovascular imaging reported.
recommends CTA as the preferred modality for imaging the (5) No clear recommendations exist for medical manage-
vasculature in acute stroke or TIA. There are well defined ment (antiplatelet and anticoagulation) versus surgi-
signs on CTA such as the “donut sign” described by Menon cal management (including carotid artery stenting,
et al. [8] (Figure 2). Jaberi et al. in their prospective single bypass, or CEA), both of which have shown similar
center study showed a cranial-caudal measurement threshold outcomes.
of more than 3.8 mm on a CTA was highly specific and
sensitive for FFT diagnosis [9]. Though smaller studies have
supported the use of DSA, CTA appears to be the most Consent
common imaging used due to easy availability. CTA has
An informed consent was obtained from the patient for
also been further studied to report specific radiological signs
publication of this paper.
to diagnose this condition. Larger studies to determine the
gold standard imaging modality in FFT need to be done. In
contrast, our case underwent emergent CT head with CTA Competing Interests
that did show a FFT in left ICA (Figures 1–3).
In the published data, different types of treatments The authors declare that there is no conflict of interests
have been described with good results: medical manage- regarding the publication of this paper.
ment, medical management with deferred surgery, urgent
endarterectomy, or endovascular treatment [2, 3, 8]. Bhatti References
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4 Case Reports in Medicine

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