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

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.

Management of Free-Floating Thrombus in the Vertebral Artery in a Middle-Aged Smoker with Secondary Polycythemia Vera

“… 3 , 4 However, few asymptomatic cases were reported in the literature. 1 Our patient was symptomatic with recurrent strokes in the posterior circulation prior to therapy initiation.…”

“… 9 Nevertheless, a successful surgical intervention via EVT in ICA-FFT and VA-FFT has also been reported. 1 , 11 A published review article by Bahtti et al 3 failed to show any superiority of either approach. As the therapeutic guideline for FFT has not been established yet, each patient should be approached, for the time being, individually in an interdisciplinary manner (neurology, neurosurgery, and neuroradiology) as we have done with our patient.…”

“…Other causes such as dissection and drug abuse are rarely reported. 7 , 9 Whereas FFT could be asymptomatic and found incidentally, 1 , 3 patients typically present with acute neurological deficits as a sequela of cerebral ischemic insult in context of transient ischemic attack (TIA) or well-established stroke. Some patients even develop evolving or current stroke.…”

Triple Stentriever “Bouquet” Deployment with Zoom 88 Large-Bore Aspiration and Walrus Balloon-Guide Catheter for the Definitive Thrombectomy of a Carotid Free-Floating Thrombus

“…5 There have been several recent reports about the successful mechanical thrombectomy of CFFT. [6][7][8][9][10][11][12][13][14][15][16][17] These studies have demonstrated the challenges of safely performing mechanical thrombectomy due to significant clot burden, lack of tools, and techniques designed to perform cerebrovascular thrombectomy. In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs.…”

“…In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs. 5,18 Recent technological improvements in aspiration catheters and stentrievers has made mechanical thrombectomy of cerebral vessels increasingly safe [6][7][8][9][10][11][12][13][14][15][16][17] and effective. 19,20 Among these developments are large-bore aspiration catheters (0.088" ID) 21,22 that are built both with and without compliant balloons for flow arrest and aspiration/flow reversal.…”