From the Guidelines
For acute ischemic stroke with free-floating carotid thrombus beyond the thrombolytic window, the best treatment approach is urgent endovascular thrombectomy using a combined approach with stent-retrievers and aspiration, as it achieves fast first-pass complete reperfusion. This approach is supported by the most recent and highest quality study, which emphasizes the importance of rapid treatment and the effectiveness of combined endovascular therapy in achieving complete reperfusion 1. The patient should be immediately transferred to a comprehensive stroke center with neurointerventional capabilities for mechanical thrombectomy to remove the clot and restore blood flow.
Key considerations in the treatment approach include:
- Urgent transfer to a comprehensive stroke center for endovascular thrombectomy
- Use of a combined approach with stent-retrievers and aspiration for mechanical thrombectomy
- Avoidance of time-consuming imaging methods and overly selective treatment selection criteria
- Maintenance of blood pressure below 180/105 mmHg but not excessively lowered to preserve cerebral perfusion
The use of anticoagulation therapy, such as intravenous unfractionated heparin, may also be considered while awaiting transfer or if thrombectomy is not available, to prevent further clot propagation and embolization. However, the primary focus should be on urgent endovascular thrombectomy, as it offers the best chance of achieving complete reperfusion and improving outcomes in patients with acute ischemic stroke due to large-vessel occlusion, including those with free-floating carotid thrombus 1.
From the Research
Acute Treatment for Acute Ischemic Stroke with Free Floating Carotid Thrombus
There are various treatment options for acute ischemic stroke with free floating carotid thrombus, including mechanical thrombectomy, antiplatelet therapy, and anticoagulation.
- Mechanical thrombectomy has been shown to be effective in improving outcomes for patients with acute ischemic stroke, with a reduction in the risk of death and improvement in functional independence 2.
- Antiplatelet therapy with Aspirin and anticoagulation with Warfarin has been used conservatively in some cases, without recurrence of transient ischemic attacks or strokes on six-month follow-up 3.
- However, there is no consensus regarding the management of carotid free-floating thrombi in patients with acute ischemic stroke and transient ischemic attack, and the diagnosis poses a high short-term risk of stroke and death 4.
- Angioplasty and stenting have also been evaluated as potential therapies for mechanical thrombectomy in acute ischemic stroke, but the current literature is limited to case reports and small series 5.
- It is essential to recognize and manage common complications of mechanical thrombectomy, including reperfusion hemorrhage, cerebral edema, and access site complications, to ensure optimal outcomes 6.
Treatment Options
- Mechanical thrombectomy: associated with a reduction in the risk of death and improvement in functional independence 2.
- Antiplatelet therapy: used conservatively in some cases, without recurrence of transient ischemic attacks or strokes on six-month follow-up 3.
- Anticoagulation: used conservatively in some cases, without recurrence of transient ischemic attacks or strokes on six-month follow-up 3.
- Angioplasty and stenting: evaluated as potential therapies for mechanical thrombectomy in acute ischemic stroke, but the current literature is limited 5.