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

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          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.

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          Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.

          A. Halliday, A. Mansfield, J. Marro … (2004)
          Among patients with substantial carotid artery narrowing but no recent neurological symptom (stroke or transient ischaemia), the balance of surgical risks and long-term benefits from carotid endarterectomy (CEA) was unclear. During 1993-2003, 3120 asymptomatic patients with substantial carotid narrowing were randomised equally between immediate CEA (half got CEA by 1 month, 88% by 1 year) and indefinite deferral of any CEA (only 4% per year got CEA) and were followed for up to 5 years (mean 3.4 years). Kaplan-Meier analyses of 5-year risks are by allocated treatment. The risk of stroke or death within 30 days of CEA was 3.1% (95% CI 2.3-4.1). Comparing all patients allocated immediate CEA versus all allocated deferral, but excluding such perioperative events, the 5-year stroke risks were 3.8% versus 11% (gain 7.2% [95% CI 5.0-9.4], p<0.0001). This gain chiefly involved carotid territory ischaemic strokes (2.7% vs 9.5%; gain 6.8% [4.8-8.8], p<0.0001), of which half were disabling or fatal (1.6% vs 5.3%; gain 3.7% [2.1-5.2], p<0.0001), as were half the perioperative strokes. Combining the perioperative events and the non-perioperative strokes, net 5-year risks were 6.4% versus 11.8% for all strokes (net gain 5.4% [3.0-7.8], p<0.0001), 3.5% versus 6.1% for fatal or disabling strokes (net gain 2.5% [0.8-4.3], p=0.004), and 2.1% versus 4.2% just for fatal strokes (net gain 2.1% [0.6-3.6], p=0.006). Subgroup-specific analyses found no significant heterogeneity in the perioperative hazards or (apart from the importance of cholesterol) in the long-term postoperative benefits. These benefits were separately significant for males and females; for those with about 70%, 80%, and 90% carotid artery narrowing on ultrasound; and for those younger than 65 and 65-74 years of age (though not for older patients, half of whom die within 5 years from unrelated causes). Full compliance with allocation to immediate CEA or deferral would, in expectation, have produced slightly bigger differences in the numbers operated on, and hence in the net 5-year benefits. The 10-year benefits are not yet known. In asymptomatic patients younger than 75 years of age with carotid diameter reduction about 70% or more on ultrasound (many of whom were on aspirin, antihypertensive, and, in recent years, statin therapy), immediate CEA halved the net 5-year stroke risk from about 12% to about 6% (including the 3% perioperative hazard). Half this 5-year benefit involved disabling or fatal strokes. But, outside trials, inappropriate selection of patients or poor surgery could obviate such benefits.
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            Diagnosis and management of acute ischemic stroke: speed is critical.

            Tapuwa D Musuka, Stephen B Wilton, Mouhieddin Traboulsi … (2015)
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              Free-floating thrombus of the carotid artery: literature review and case reports.

              Hugo L. Leon, F Bhatti, José Biller … (2006)
              Free-floating thrombus (FFT) of the carotid artery is an uncommon entity that usually presents as an acute emergency. Management is based on case reports and series because the natural history and optimal treatment are unknown. This study was conducted to systematically review the world literature in an attempt to better understand FFT, its presentation, distribution, management, and outcome. A literature search in all languages was performed of the PubMed database (> or =1950s) and Medline database (1966-November 2004). All relevant articles were reviewed and their references analyzed in a similar manner for further literature. Cases from the authors' institutions were reviewed as well. All cases within the reports were individually assessed for inclusion or exclusion. Inclusion required that the FFT originate or anchor within the carotid artery (ie, excluding emboli, arch thrombi with extensions into the carotid artery), be partially occluding (ie, excluding occlusions, "string-sign," microscopic thrombus), and ideally have an elongated or protrusive morphology, circumferential flow around the distal portion, and cyclical motion with the cardiac cycles. There were 61 reports reviewed, of which 43 contained FFT cases. These reports had 342 cases (including the current series) that were reviewed, of which 145 met our inclusion criteria. A database was created for qualitative and quantitative assessment of all cases. When data were pooled, appropriate statistical analysis was performed. A limitation of the study is that FFT is under-reported and ill defined, which limited the analysis in quantity and quality. In addition, reporting is not uniform, and therefore, significant data were not always present. In attempting to define FFT and include or exclude cases, subjectivity is inherent. FFT is more frequently reported in men than women, with a ratio of nearly 2:1 (P < .0001), and at a younger age than in most patients with carotid disease (P < .0001 when compared with North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial, and Asymptomatic Carotid Surgery Trial). Symptoms are present in 92% of patients. There was a trend for patients with FFT to be hypercoagulable (47% of those serologically tested). The internal carotid artery was the most commonly affected (75%), with atherosclerosis being the most common associated pathology. Medical and surgical management have both been used, with neither clearly superior to the other. Medical management for stabilizing neurologic deficits has less risk and less benefit than surgical intervention.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Neurointervention
                Journal ID (iso-abbrev): Neurointervention
                Journal ID (publisher-id): NI
                Title: Neurointervention
                Publisher: Korean Society of Interventional Neuroradiology
                ISSN (Print): 2093-9043
                ISSN (Electronic): 2233-6273
                Publication date (Print): November 2020
                Publication date (Electronic): 11 August 2020
                Volume: 15
                Issue: 3
                Pages: 144-153
                Affiliations
                [1 ]Department of Neurosurgery, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
                [2 ]Department of Neurology and Neursurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
                [3 ]Department of Neurology, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
                [4 ]Department of Medicine, Royal Commision Hospital, Jubail, Saudi Arabia
                Author notes
                Correspondence to: Hosam Al-Jehani, MBBS, MSc, FRCSC Department of Neurology and Neursurgery, Montreal Neurological Institute and Hospital, McGill University, c/o Luisa Birri, 3801 University St., Suite 109, Montreal, QC, H3A 2B4, Canada Tel: +1-514-398-1935 Fax: +1-514-398-2811 E-mail: hjehani@ 123456iau.edu.sa
                Author information
                http://orcid.org/0000-0002-3830-9789
                http://orcid.org/0000-0002-4521-1827
                http://orcid.org/0000-0003-4392-5233
                Article
                Publisher ID: neuroint-2020-00087
                DOI: 10.5469/neuroint.2020.00087
                PMC ID: 7608498
                PubMed ID: 32777873
                SO-VID: d3cc2af4-c9da-40d4-bd2e-99fb85297dce
                Copyright © Copyright © 2020 Korean Society of Interventional Neuroradiology
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 19 March 2020
                Date revision received : 20 July 2020
                Date accepted : 21 July 2020
                Categories
                Subject: Case Series

                ScienceOpen disciplines: Neurosciences
                Keywords: free-floating thrombus,vertebral artery,middle cerebral artery,acute ischemic stroke,thrombectomy
                Data availability:
                ScienceOpen disciplines: Neurosciences
                Keywords: free-floating thrombus, vertebral artery, middle cerebral artery, acute ischemic stroke, thrombectomy

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