Rapid Resolution of Newly Formed Carotid Free-Floating Thrombus Through Anticoagulation Therapy

Rapid Resolution of Newly Formed Carotid Free-Floating Thrombus Through Anticoagulation Therapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rapid Resolution of Newly Formed Carotid Free-Floating Thrombus Through Anticoagulation Therapy Fuli Xie, Lili Liang, Yuzhou Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4423019/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2025 Read the published version in BMC Neurology → Version 1 posted 10 You are reading this latest preprint version Abstract Background Carotid free-floating thrombus (CFFT) are rare but carry significant risks of ischemic strokes. While the predominant treatment modality typically involves vascular intervention, in this case study, we highlight the feasibility of alternative options, specifically short-term anticoagulation therapy guided by extensive radiological evaluation. Case presentation: We admitted a patient with acute ischemic stroke due to middle cerebral artery (MCA) occlusion, and the National Institutes of Health Stroke Score (NIHSS) was 15. The patient was satisfactorily revascularized by prompt intravenous alteplase thrombolysis, but a rare occurrence of carotid free-floating thrombus was found, which was the culprit for the occlusion of the MCA. Instead of surgical treatment, we performed extensive radiological evaluations for the thrombus, including high-resolution magnetic resonance and serial ultrasonic scans. The intramural thrombus is highly suspected to be newly formed, so we hypothesized it might respond to anticoagulant therapy. As expected, after short-term anticoagulant therapy of enoxaparin injection, CFFT significantly dissolved. Conclusions This case illustrates the efficacy of anticoagulation for newly formed CFFT and introduces a novel treatment protocol guided by extensive radiological evaluation. Carotid free-floating thrombus Ischemic Stroke Radiology Anticoagulation Figures Figure 1 Figure 2 Background A carotid free-floating thrombus (CFFT) is a clot attached to the carotid artery wall, exhibiting periodic fluctuations with the cardiac cycle [ 1 ]. The etiology of CFFT is diverse and commonly attributed to atherosclerosis and hypercoagulation [ 2 ]. Given the rarity of the thrombus, current treatment approaches typically rely on expert opinions or institutional experiences. Considering the significant risks associated with artery occlusion, the instinctive use of mechanical thrombectomy for thrombus retrieval is rational and unquestionable. Consequently, there is limited research evaluating thrombus characteristics before this procedure. In this case, we present alternative options and provide supporting evidence that anticoagulant therapy can be equally effective and prompt, particularly in the context of a recently formed thrombus. Case presentation A 53-year-old woman was admitted to our department following the sudden onset of limb weakness and slurred speech, persisting for 30 minutes. With no medical history of diabetes, hypertension, or atrial fibrillation, she underwent a neurological examination that revealed dysarthria, left-sided facial, tongue, and limb paralysis (upper limb, MRC I grade; lower limb, MRC II grade), resulting in a National Institutes of Health Stroke Score (NIHSS) of 15. A non-contrast CT scan of the brain showed no abnormalities. The CT angiography (CTA) source image, however, revealed a filling deficit in the distal segment of the right middle cerebral artery (MCA) and hypoperfusion in the corresponding vascular territory, encompassing the frontal, parietal, and temporal lobes of the right hemisphere. The diagnosis of acute ischemic stroke was confirmed, leading to the prompt administration of a standard intravenous alteplase dose (0.9 mg/kg) within one hour. Notably, the patient exhibited significant neurological improvement, nearly resolving her symptoms by the following day (NIHSS = 1). Risk factors for stroke in this patient encompassed elevated serum D-dimer levels at 3.86 µg/ml (normal range: 0 to 0.5 µg/ml) and increased cholesterol levels of 8.09 mmol/l (normal range: 2.9 to 5.68 mmol/l). Nevertheless, the most noteworthy revelation was the identification of an unanticipated CFFT, which was tethered to a 5.8 mm × 2.1 mm irregular-shaped, heterogeneously echogenic plaque on the posterior wall of the right carotid bifurcation. With dimensions measuring approximately 7.7 mm × 1.9 mm, the thrombus displayed a distinctive low echo floating signal at its distal end (Fig. 1 a). Validation through high-resolution MR scans further substantiated this surprising discovery, confirming the presence of the thrombus and revealing contrast enhancement in the blood vessel wall (Fig. 2 ). Based on the unique radiologic features of the plaque it was considered that CFFT may have formed from plaque rupture. Anticoagulation by subcutaneous injection of enoxaparin (4000 U) twice daily for ten consecutive days and subsequent dual antiplatelet therapy resulted in rapid dissolution of the thrombus (Fig. 1 b) and almost complete disappearance within one month (Fig. 1 c). DISCUSSION CFFT occurs in about 1.6% of patients with ischemic stroke [ 3 ]. However, it is associated with a high risk of embolic ischemic events, so over 90% of patients are symptomatic [ 1 ]. Atherosclerosis and hypercoagulability are the most common causes of CFFT because mural thrombosis usually occurs after a localized atherosclerotic plaque rupture [ 4 , 5 ]. Due to the rare occasions of the disease, randomized comparative trials systematically evaluating pharmacological (anticoagulation, antiplatelet, thrombolysis) or interventional treatment (endovascular or surgical) are not available [ 6 ]. Hence, consensus has yet to be reached on the best treatment strategy. Previous anticoagulant therapy resulted in the complete dissolution of FFTs without complications in 86% of patients [ 1 ]. D M Pelz et al. found that thrombosis in the lumen of the internal carotid artery could be resolved by anticoagulation. Seven patients in eight cases were treated with anticoagulation, and the thrombus wholly disappeared. In one patient, the thrombus size steadily decreased [ 7 ]. Karapurkar A P et al. reported a case of transient ischemic attack, in which a CFFT appeared in the distal internal carotid artery, and the thrombus was wholly dissolved after three weeks of treatment with enoxaparin [ 8 ]. In this case study, imaging characteristics of the thrombus show that it is newly formed, so it responds well to anticoagulant therapy. These findings have important clinical significance for those patients who do not agree to surgery or have surgical contraindications. A treatment plan based on the radiological characteristics of thrombus can provide alternative treatment options for patients with CFFT. In conclusion, we report a case of ischemic stroke that was induced by CFFT, which was confirmed by Doppler ultrasound and carotid magnetic resonance scanning. Anticoagulation therapy based on detailed imaging evaluation of thrombosis has proved safty and effectiveness. Abbreviations CFFT Carotid free-floating thrombus MCA Middle cerebral artery NIHSS National Institutes of Health Stroke Score CTA CT angiography Declarations Data availability Data sharing does not apply to this article as no datasets were generated or analyzed during the current study. Acknowledgements The authors thank the patient for her participation in this study. Funding None. Contributions FLX and LLL collected patient information and drafted the manuscript. YZ W collected the data and figures, and revised the manuscript. All authors read and approved the final manuscript. Ethics declarations Ethics approval and consent to participate Written informed consent was obtained from patient. Consent for publication Written informed consent regarding the submission and potential publication of this manuscript was obtained from patient. Competing interests The authors declare no competing interests. References Bhatti AF, Leon LR Jr., Labropoulos N, et al. Free-floating thrombus of the carotid artery: literature review and case reports[J]. J Vasc Surg. 2007;45(1):199–205. Richard S, Mione G, Perrin J, et al. Internal carotid thrombus in patients with inflammatory bowel disease: two cases[J]. World J Gastroenterol. 2013;19(5):773–5. Singh RJ, Chakraborty D, Dey S, et al. Intraluminal Thrombi in the Cervico-Cephalic Arteries[J]. Stroke. 2019;50(2):357–64. Fridman S, Lownie SP, Mandzia J. Diagnosis and management of carotid free-floating thrombus: A systematic literature review[J]. Int J Stroke. 2019;14(3):247–56. Dowlatshahi D, Lum C, Menon BK, et al. Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort[J]. Stroke Vasc Neurol. 2023;8(3):194–6. Müller MD, Raptis N, Mordasini P et al. Natural history of carotid artery free-floating thrombus-A single center, consecutive cohort analysis[J]. Front Neurol, 2022, 13(993559. Pelz DM, Buchan A, Fox AJ, et al. Intraluminal thrombus of the internal carotid arteries: angiographic demonstration of resolution with anticoagulant therapy alone[J]. Radiology. 1986;160(2):369–73. Karapurkar AP, Singh R, Teelala SM et al. Free-floating thrombus in a stenotic supraclinoid left internal carotid artery[J]. BMJ Case Rep, 2016, 2016:bcr2015213067. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Mar, 2025 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 05 Dec, 2024 Reviews received at journal 01 Sep, 2024 Reviewers agreed at journal 12 Aug, 2024 Reviews received at journal 05 Aug, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers invited by journal 22 Jul, 2024 Editor invited by journal 20 May, 2024 Editor assigned by journal 15 May, 2024 Submission checks completed at journal 15 May, 2024 First submitted to journal 15 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4423019","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":305998240,"identity":"5a5f303c-fd3c-41a1-ab15-d809f3593f15","order_by":0,"name":"Fuli Xie","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Fuli","middleName":"","lastName":"Xie","suffix":""},{"id":305998241,"identity":"9c52b598-4e83-4064-9837-4f472e1157f3","order_by":1,"name":"Lili Liang","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Lili","middleName":"","lastName":"Liang","suffix":""},{"id":305998243,"identity":"98da90c0-96ce-4657-b323-ac3751d80b58","order_by":2,"name":"Yuzhou Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYPCCA3Ly7A0wNpFajA17YEqJ1ZLYcCOBSC0Gx88efs3z505i48znzyR/tjHI8d1IYPxcgE/Lmbw0ax6eZ8bt0jlm0rxtDMaSNxKYpWfg0WJ2IMfMmEfisGzj7Bw2acY2hsQNNxLYmHnwaTn/BqjF4DBjw83jYIfVE9ZyI8f4MU/CYcWGGwxmEkCHJRgQ0mJ/440Z45wDh4GBnGNszXNOwnDmmYfN0vi0SPbnGH948+cwMCqPP7z5o8xGnu948sHP+LQAAZsUVAGLBAMDEDEwNuDXwMDA/PEHlPGBkNJRMApGwSgYmQAAUlJRmayPUFYAAAAASUVORK5CYII=","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Yuzhou","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-05-15 06:36:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4423019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4423019/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-025-04062-2","type":"published","date":"2025-03-12T15:58:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57449097,"identity":"f8f9b427-3088-431c-9cab-ccb29421389d","added_by":"auto","created_at":"2024-05-30 20:06:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":449915,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonic Doppler scan of right carotid artery unveils a free-floating thrombus situated in the bifurcation (a). Notably, significant improvement is evident on the 10th day post-treatment, with a substantial reduction in the size of the CFFT (b). Continued dissolution is observed on the 26th day, with the thrombus nearly disappearing entirely (c).\u003c/p\u003e","description":"","filename":"FIG.11.png","url":"https://assets-eu.researchsquare.com/files/rs-4423019/v1/d9e6a7c794fdfcc7b4ad5ea0.png"},{"id":57448521,"identity":"5f16a6b2-6c87-4b10-8752-a60c99af6892","added_by":"auto","created_at":"2024-05-30 19:58:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":386457,"visible":true,"origin":"","legend":"\u003cp\u003eThrombosis and atherosclerotic plaque in the right carotid arter (coronal plane). In both T1 (a) and T2 (b) weighted images, these lesions appear indistinct and blurred, making it challenging to differentiate between them. However, after enhancement, the wall of the carotid artery (red triangle, c-g) and internal carotid artery becomes clearly visible. The thrombus, indicated by a blue arrow in images c-i, exhibits an isointensity signal, protruding into the vascular wall on the opposite side and lacking enhancement. The associated plaque, highlighted by red arrows in images h-i, presents with a heterogeneous signal, and the thrombus is visibly attached to it.\u003c/p\u003e","description":"","filename":"FIG.2.png","url":"https://assets-eu.researchsquare.com/files/rs-4423019/v1/2b6eb8129b09b929c9615de6.png"},{"id":78689263,"identity":"341cf5e0-d803-4ecd-aade-5b138070bc2b","added_by":"auto","created_at":"2025-03-17 16:12:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1517885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4423019/v1/8e934af7-81dd-4005-91cb-1451d375aa0d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rapid Resolution of Newly Formed Carotid Free-Floating Thrombus Through Anticoagulation Therapy","fulltext":[{"header":"Background","content":"\u003cp\u003eA carotid free-floating thrombus (CFFT) is a clot attached to the carotid artery wall, exhibiting periodic fluctuations with the cardiac cycle [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The etiology of CFFT is diverse and commonly attributed to atherosclerosis and hypercoagulation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Given the rarity of the thrombus, current treatment approaches typically rely on expert opinions or institutional experiences. Considering the significant risks associated with artery occlusion, the instinctive use of mechanical thrombectomy for thrombus retrieval is rational and unquestionable. Consequently, there is limited research evaluating thrombus characteristics before this procedure. In this case, we present alternative options and provide supporting evidence that anticoagulant therapy can be equally effective and prompt, particularly in the context of a recently formed thrombus.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 53-year-old woman was admitted to our department following the sudden onset of limb weakness and slurred speech, persisting for 30 minutes. With no medical history of diabetes, hypertension, or atrial fibrillation, she underwent a neurological examination that revealed dysarthria, left-sided facial, tongue, and limb paralysis (upper limb, MRC I grade; lower limb, MRC II grade), resulting in a National Institutes of Health Stroke Score (NIHSS) of 15. A non-contrast CT scan of the brain showed no abnormalities. The CT angiography (CTA) source image, however, revealed a filling deficit in the distal segment of the right middle cerebral artery (MCA) and hypoperfusion in the corresponding vascular territory, encompassing the frontal, parietal, and temporal lobes of the right hemisphere. The diagnosis of acute ischemic stroke was confirmed, leading to the prompt administration of a standard intravenous alteplase dose (0.9 mg/kg) within one hour. Notably, the patient exhibited significant neurological improvement, nearly resolving her symptoms by the following day (NIHSS\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eRisk factors for stroke in this patient encompassed elevated serum D-dimer levels at 3.86 \u0026micro;g/ml (normal range: 0 to 0.5 \u0026micro;g/ml) and increased cholesterol levels of 8.09 mmol/l (normal range: 2.9 to 5.68 mmol/l). Nevertheless, the most noteworthy revelation was the identification of an unanticipated CFFT, which was tethered to a 5.8 mm \u0026times; 2.1 mm irregular-shaped, heterogeneously echogenic plaque on the posterior wall of the right carotid bifurcation. With dimensions measuring approximately 7.7 mm \u0026times; 1.9 mm, the thrombus displayed a distinctive low echo floating signal at its distal end (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Validation through high-resolution MR scans further substantiated this surprising discovery, confirming the presence of the thrombus and revealing contrast enhancement in the blood vessel wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on the unique radiologic features of the plaque it was considered that CFFT may have formed from plaque rupture. Anticoagulation by subcutaneous injection of enoxaparin (4000 U) twice daily for ten consecutive days and subsequent dual antiplatelet therapy resulted in rapid dissolution of the thrombus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) and almost complete disappearance within one month (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCFFT occurs in about 1.6% of patients with ischemic stroke [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, it is associated with a high risk of embolic ischemic events, so over 90% of patients are symptomatic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Atherosclerosis and hypercoagulability are the most common causes of CFFT because mural thrombosis usually occurs after a localized atherosclerotic plaque rupture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Due to the rare occasions of the disease, randomized comparative trials systematically evaluating pharmacological (anticoagulation, antiplatelet, thrombolysis) or interventional treatment (endovascular or surgical) are not available [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hence, consensus has yet to be reached on the best treatment strategy. Previous anticoagulant therapy resulted in the complete dissolution of FFTs without complications in 86% of patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. D M Pelz et al. found that thrombosis in the lumen of the internal carotid artery could be resolved by anticoagulation. Seven patients in eight cases were treated with anticoagulation, and the thrombus wholly disappeared. In one patient, the thrombus size steadily decreased [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Karapurkar A P et al. reported a case of transient ischemic attack, in which a CFFT appeared in the distal internal carotid artery, and the thrombus was wholly dissolved after three weeks of treatment with enoxaparin [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this case study, imaging characteristics of the thrombus show that it is newly formed, so it responds well to anticoagulant therapy. These findings have important clinical significance for those patients who do not agree to surgery or have surgical contraindications. A treatment plan based on the radiological characteristics of thrombus can provide alternative treatment options for patients with CFFT.\u003c/p\u003e \u003cp\u003eIn conclusion, we report a case of ischemic stroke that was induced by CFFT, which was confirmed by Doppler ultrasound and carotid magnetic resonance scanning. Anticoagulation therapy based on detailed imaging evaluation of thrombosis has proved safty and effectiveness.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFFT \u0026nbsp; Carotid free-floating thrombus\u003c/p\u003e\n\u003cp\u003eMCA \u0026nbsp; \u0026nbsp;Middle cerebral artery\u003c/p\u003e\n\u003cp\u003eNIHSS \u0026nbsp; National Institutes of Health Stroke Score\u003c/p\u003e\n\u003cp\u003eCTA \u0026nbsp; CT angiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing does not apply to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patient for her participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFLX and LLL collected patient information and drafted the manuscript. YZ W collected the data and figures, and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent regarding the submission and potential publication of this manuscript was obtained from patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBhatti AF, Leon LR Jr., Labropoulos N, et al. Free-floating thrombus of the carotid artery: literature review and case reports[J]. J Vasc Surg. 2007;45(1):199\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichard S, Mione G, Perrin J, et al. Internal carotid thrombus in patients with inflammatory bowel disease: two cases[J]. World J Gastroenterol. 2013;19(5):773\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh RJ, Chakraborty D, Dey S, et al. Intraluminal Thrombi in the Cervico-Cephalic Arteries[J]. Stroke. 2019;50(2):357\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFridman S, Lownie SP, Mandzia J. Diagnosis and management of carotid free-floating thrombus: A systematic literature review[J]. Int J Stroke. 2019;14(3):247\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowlatshahi D, Lum C, Menon BK, et al. Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort[J]. Stroke Vasc Neurol. 2023;8(3):194\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;ller MD, Raptis N, Mordasini P et al. Natural history of carotid artery free-floating thrombus-A single center, consecutive cohort analysis[J]. Front Neurol, 2022, 13(993559.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePelz DM, Buchan A, Fox AJ, et al. Intraluminal thrombus of the internal carotid arteries: angiographic demonstration of resolution with anticoagulant therapy alone[J]. Radiology. 1986;160(2):369\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarapurkar AP, Singh R, Teelala SM et al. Free-floating thrombus in a stenotic supraclinoid left internal carotid artery[J]. BMJ Case Rep, 2016, 2016:bcr2015213067.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Carotid free-floating thrombus, Ischemic Stroke, Radiology, Anticoagulation","lastPublishedDoi":"10.21203/rs.3.rs-4423019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4423019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCarotid free-floating thrombus (CFFT) are rare but carry significant risks of ischemic strokes. While the predominant treatment modality typically involves vascular intervention, in this case study, we highlight the feasibility of alternative options, specifically short-term anticoagulation therapy guided by extensive radiological evaluation.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe admitted a patient with acute ischemic stroke due to middle cerebral artery (MCA) occlusion, and the National Institutes of Health Stroke Score (NIHSS) was 15. The patient was satisfactorily revascularized by prompt intravenous alteplase thrombolysis, but a rare occurrence of carotid free-floating thrombus was found, which was the culprit for the occlusion of the MCA. Instead of surgical treatment, we performed extensive radiological evaluations for the thrombus, including high-resolution magnetic resonance and serial ultrasonic scans. The intramural thrombus is highly suspected to be newly formed, so we hypothesized it might respond to anticoagulant therapy. As expected, after short-term anticoagulant therapy of enoxaparin injection, CFFT significantly dissolved.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case illustrates the efficacy of anticoagulation for newly formed CFFT and introduces a novel treatment protocol guided by extensive radiological evaluation.\u003c/p\u003e","manuscriptTitle":"Rapid Resolution of Newly Formed Carotid Free-Floating Thrombus Through Anticoagulation Therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 19:58:17","doi":"10.21203/rs.3.rs-4423019/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-05T19:07:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T12:07:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253654128543376123172198835481862868908","date":"2024-08-12T07:43:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-05T23:14:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35378347913474501238427863784741734620","date":"2024-07-25T17:17:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-22T10:14:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-20T14:31:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-15T12:37:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-15T12:37:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2024-05-15T06:35:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"675d226c-b3cd-4afa-ae52-218e0adb7c69","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:08:09+00:00","versionOfRecord":{"articleIdentity":"rs-4423019","link":"https://doi.org/10.1186/s12883-025-04062-2","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2025-03-12 15:58:34","publishedOnDateReadable":"March 12th, 2025"},"versionCreatedAt":"2024-05-30 19:58:17","video":"","vorDoi":"10.1186/s12883-025-04062-2","vorDoiUrl":"https://doi.org/10.1186/s12883-025-04062-2","workflowStages":[]},"version":"v1","identity":"rs-4423019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4423019","identity":"rs-4423019","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}