Neurointervention.  2020 Nov;15(3):144-153. 10.5469/neuroint.2020.00087.

A Case of Coincidental Free Floating Thrombus in the Vertebral Artery in a Patient Presenting with an Anterior Circulation Stroke and Literature Review

Affiliations
  • 1Department of Neurosurgery, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
  • 2Department of Neurology and Neursurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
  • 3Department of Neurology, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
  • 4Department of Medicine, Royal Commision Hospital, Jubail, Saudi Arabia

Abstract

Free-floating thrombus (FFT) is a rare condition with unknown etiology as described by many case reports presented in previous literature. The patients usually present symptomatically while the other few patients remain asymptomatic and are usually discovered incidentally on computed tomography angiography (CTA). Most of the cases reported in the literature are of FFT in the internal carotid artery. We present a 59-year-old female as a case of FFT in the vertebral artery which was coincidently discovered on CTA in a patient initially presenting with an anterior circulation stroke. This case highlights the importance of early contrast-based vascular imaging in patients presenting with large vessel strokes that are cardioembolic in nature and the unique utilization of a direct aspiration first pass technique (ADAPT) for revascularization. Included herein an extensive review of the literature about the decision making in patients with FFT and a devised proposed practical approach to this entity.

Keyword

Free-floating thrombus; Vertebral artery; Middle cerebral artery; Acute ischemic stroke; Thrombectomy

Figure

  • Fig. 1. Magnetic resonance imaging brain showing the sizable right middle cerebral artery (MCA) territory ischemic stroke on FLAIR imaging (upper panel). The magnetic resonance angiography shows the occlusion of the superior branch of the right MCA (lower panel).

  • Fig. 2. Computed tomography angiography with axial and sagittal demonstration of the free-floating thrombus in the right vertebral artery at the junction of the V3-4 segment. R, right; L, left.

  • Fig. 3. Diagnostic and interventional angiogram. (A) Left vertebral angiographic run showing no cross flow into the right vertebral artery. (B) The right vertebral angiographic run showing the filling defect of the free-floating thrombus (FFT) with minimal contrast flow into the distal vertebral artery. (C) The aspirated fragments of the FFT. (D) Right vertebral angiographic run post contact aspiration showing no flow limitation in the vertebral artery with mild stenosis at the V3-4 junction with sluggish flow in the right posterior-inferior cerebellar artery.

  • Fig. 4. Post thrombectomy diffusion weighted magnetic resonance imaging showing no ischemic event in the posterior circulation territory.

  • Fig. 5. A proposed practical approach to free-floating thrombus (FFT). CEA, carotid endarterectomy; EVT, endovascular therapy.


Reference

1. Chiari H. Uber das verhalten des teilungswinkels der carotis communis bei der endarteritis chronica deformans. Verh Dtsch Ges Pathol. 1905; 9:326–330. German.
2. Devuyst G, de Bray JM, Despland PA, Maeder P, Meuli R, Uské A, et al. Focal adherent thrombus in the common carotid artery: clinical, ultrasonographic, and pathogenic aspects in two cases. J Ultrasound Med. 2000; 19:707–711.
Article
3. Giragani S, Balani A, Agrawal V. Stentriever thrombectomy with distal protection device for carotid free floating thrombus: a technical case report. J Neurointerv Surg. 2017; 9:e33.
Article
4. Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ. 2015; 187:887–893.
Article
5. Jaberi A, Lum C, Stefanski P, Thornhill R, Iancu D, Petrcich W, et al. Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus. Neuroradiology. 2014; 56:15–23.
Article
6. Combe J, Poinsard P, Besancenot J, Camelot G, Cattin F, Bonneville JF, et al. Free-floating thrombus of the extracranial internal carotid artery. Ann Vasc Surg. 1990; 4:558–562.
Article
7. Roy M, Roy AK, DeSanto JR, Abdelsalam M. Free floating thrombus in carotid artery in a patient with recurrent strokes. Case Rep Med. 2017; 2017:4932567.
Article
8. Bhatti AF, Leon LR Jr, Labropoulos N, Rubinas TL, Rodriguez H, Kalman PG, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg. 2007; 45:199–205.
Article
9. Biller J, Adams HP Jr, Boarini D, Godersky JC, Smoker WR, Kongable G. Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review. Surg Neurol. 1986; 25:467–477.
Article
10. Menon BK, Singh J, Al-Khataami A, Demchuk AM, Goyal M; Calgary CTA Study Group. The donut sign on CT angiography: an indicator of reversible intraluminal carotid thrombus? Neuroradiology. 2010; 52:1055–1056.
Article
11. Puetz V, Dzialowski I, Coutts SB, Hill MD, Krol A, O’Reilly C, Calgary CTA Study Group, et al. Frequency and clinical course of stroke and transient ischemic attack patients with intracranial nonocclusive thrombus on computed tomographic angiography. Stroke. 2009; 40:193–199.
Article
12. Singh RJ, Chakraborty D, Dey S, Ganesh A, Al Sultan AS, Eesa M, et al. Intraluminal thrombi in the cervico-cephalic arteries. Stroke. 2019; 50:357–364.
Article
13. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004; 363:1491–1502.
14. Gülcü A, Gezer NS, Men S, Öz D, Yaka E, Öztürk V. Management of free-floating thrombus within the arcus aorta and supra-aortic arteries. Clin Neurol Neurosurg. 2014; 125:198–206.
Article
15. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2018; 10(Suppl 1):i4–i7.
Article
16. Tan AP, Taneja M, Seah BH, Leong HN, Venketasubramanian N. Acute free-floating carotid artery thrombus causing stroke in a young patient: unique etiology and management using endovascular approach. J Stroke Cerebrovasc Dis. 2014; 23:e437–e439.
Article
17. Fitzpatrick N, Motyer R, Gibney B, Duffy S, Murphy S, O’Brien P, et al. Expanding the role of stent-retriever endovascular thrombectomy: a case series of free-floating thrombus. J Neurointerv Surg. 2018; 10:1164–1167.
Article
18. Härtl J, Mühlau M, Pernpeintner V, Seifert C, Kreiser K, Schäffer C, et al. Clinical implications of the incidental finding of a free-floating thrombus in the internal carotid artery. [published online ahead of print Jan 19, 2020]. J Clin Ultrasound. 2020.
Article
19. Imahori T, Tanaka K, Arai A, Kohmura E. Surgical thromboendarterectomy for free-floating thrombus associated with cervical carotid artery dissection: a case report. [published online ahead of print May 18, 2020]. Ann Vasc Surg. 2020.
Article
20. Bhogal P, AlMatter M, Aguilar Pérez M, Bäzner H, Henkes H, Hellstern V. Carotid stenting as definitive treatment for free floating thrombus-review of 7 cases. [published online ahead of print Mar 27 2020]. Clin Neuroradiol. 2020.
Article
21. Afsharfard A, Gholizadeh B, Abdolalian Y, Hosseini SM. Carotid free-floating thrombus causing stroke in a young woman with lupus anticoagulant: a case report and review of the literature. Int J Surg Case Rep. 2017; 33:35–37.
Article
22. Tolaymat B, Irizarry K, Reif M, Drucker CB, Aicher BO, Sarkar R, et al. Considerations beyond stenosis for carotid endarterectomy in treating free-floating thrombus of the carotid artery. Ann Vasc Surg. 2019; 60:221–228.
Article
23. Yamaoka A, Miyata K, Iihoshi S, Mikuni N. Endovascular treatment of asymptomatic free-floating thrombus in the carotid artery bifurcation: a direct aspiration first-pass technique under double balloon protection. BMJ Case Rep. 2019; 12:e230295.
Article
24. Ascoli Marchetti A, Diomedi M, Ascoli Marchetti S, Piccione E, Ippoliti A. Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: surgical technical success and maintenance of pregnancy. SAGE Open Med Case Rep. 2019; 7:2050313. X19831117.
Article
25. Emamikhah M, Yazdi N, Mohebi N, Eslami M, Moghaddasi M. Anemia: an unusual cause of free-floating thrombus of carotid artery. Iran J Neurol. 2019; 18:87–89.
Article
26. Yamaguchi S, Hamabe J, Yamashita A, Irie J, Yagi N, Suyama K. Rare case of floating intimal flap associated with atheromatous carotid plaque. World Neurosurg. 2019; 122:98–101.
Article
27. Fridman S, Lownie SP, Mandzia J. Diagnosis and management of carotid free-floating thrombus: a systematic literature review. Int J Stroke. 2019; 14:247–256.
Article
28. Carr K, Tew D, Becerra L, Siddall K, Dubensky L, Serulle Y. Endovascular aspiration of a symptomatic free-floating common carotid artery thrombus. Neuroradiology. 2018; 60:1103–1107.
Article
29. Bae E, Vo TD. Carotid artery angioplasty and stenting for atherosclerotic plaque with mobile intimal flap. Ann Vasc Surg. 2018; 49:310.e1–310.e3.
Article
30. Tanriverdi U, Kizilkilic O, Ince B. Huge free-floating thrombus in the internal carotid artery. J Stroke Cerebrovasc Dis. 2017; 26:3029–3030.
Article
31. Graham BR, Menon BK. Clopidogrel load reduces emboli in carotid artery stenosis with free-floating thrombus. Can J Neurol Sci. 2017; 44:594–596.
Article
32. Karapurkar AP, Singh R, Teelala SM, Lalla R. Free-floating thrombus in a stenotic supraclinoid left internal carotid artery. BMJ Case Rep. 2016; 2016:bcr2015213067.
Article
33. Leško MlM, Guňka I, Lojík M, Krajíčková D. [Free-floating thrombus in the internal carotid artery treated by anticoagulation and delayed carotid endarterectomy]. Rozhl Chir. 2016; 95:325–328. Czech.
34. Frías Vargas M, Tavera Santos E, Carrasco Carrasco E, López Uriarte B. [Free floating thrombus in the internal carotid and vascular risk: Presentation of a case]. Semergen. 2016; 42:274–276. Spanish.
35. Santoro L, Schinzari F, Di Veronica A, Cardillo C, Santoliquido A. Carotid free-floating thrombus in woman with meningioma: a case report and review of the literature. Eur Rev Med Pharmacol Sci. 2015; 19:1442–1445.
36. Vassileva E, Daskalov M, Stamenova P. Free-floating thrombus in stroke patients with nonstenotic internal carotid artery-an ultrasonographic study. J Clin Ultrasound. 2015; 43:34–38.
Article
37. Bajkó Z, Maier S, Rusu S, Moțățăianu A. Acute ischaemic stroke secondary to a mobile thrombus in the common carotid artery: case report. J Crit Care Med (Targu Mures). 2015; 1:68–70.
38. Ferrero E, Ferri M, Viazzo A, Labate C, Pecchio A, Berardi G, et al. Free-floating thrombus in the internal carotid artery: diagnosis and treatment of 16 cases in a single center. Ann Vasc Surg. 2011; 25:805–812.
Article
39. La Spada M, Stilo F, Barillà D, Spinelli F. A big floating thrombus in the common carotid artery. J Cardiovasc Med (Hagerstown). 2011; 12:819–820.
Article
40. Lane TR, Shalhoub J, Perera R, Mehta A, Ellis MR, Sandison A, et al. Diagnosis and surgical management of free-floating thrombus within the carotid artery. Vasc Endovascular Surg. 2010; 44:586–593.
Article
41. Yonemura K, Kimura K, Yasaka M, Minematsu K. Disappearance of an oscillating intraluminal thrombus in the carotid artery demonstrated by ultrasonography. Intern Med. 2003; 42:746–749.
Article
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