Intraluminal Thrombi in the Cervico-Cephalic Arteries

Abstract

Background and Purpose— Intraluminal thrombus (ILT) is an uncommon finding among patients with ischemic stroke. We report clinical-imaging manifestations, treatment offered, and outcome among patients with ischemic stroke/transient ischemic attack and ILT in their cervico-cephalic arteries. Methods— Sixty-one of 3750 consecutive patients with acute ischemic stroke/transient ischemic attack (within 24 hours of onset) and ILT on initial arch-to-vertex computed tomography angiography from April 2015 through September 2017 constituted the prospective study cohort. Functional outcome was assessed using the modified Rankin Scale score with functional independence at discharge defined as modified Rankin Scale score ≤2. Results— Prevalence of ILT on computed tomography angiography was 1.6% (95% CI, 1.2%–2.1%). Median age was 67 years (interquartile range, 56–73), and 40 subjects (65%) were male. The initial clinical presentation included transient ischemic attack in 12 (20%) and stroke in 49 patients (80%); most strokes (76%) were mild (National Institutes of Health Stroke Scale ≤5). The most common ILT location was cervical carotid or vertebral artery (n=48 [79%]) followed by intracranial (n=11 [18%]) and tandem lesions (n=2 [3%]). The most common initial treatment strategy was combination antithrombotics (heparin with single antiplatelet agent) among 57 patients (93%). Follow-up computed tomography angiography (n=59), after a median 6 days (interquartile range 4–10 days), revealed thrombus resolution in 44 patients (75% [completely in 27%]). Twenty four of 30 patients (80%) with >50% residual carotid stenosis underwent carotid revascularization (endarterectomy in 15 and stenting in 9 patients) without peri-procedural complications a median of 9 days after symptom onset. In-hospital stroke recurrence occurred in 4 patients (6.6%). Functional independence was achieved in 46 patients (75%) at discharge. Conclusions— Patients presenting with acute stroke/transient ischemic attack with ILT on baseline imaging have a favorable clinical course in hospital with low stroke recurrence, high rate of thrombus resolution, and good functional outcome when treated with combination antithrombotic therapy.

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

“…These were also termed intraluminal thrombus (ILT), intraluminal clot and were referred to as the doughnut sign [ 9 , 10 ]. Studies based on catheter angiography reported a prevalence of FFT ranging from 0.4% to 1.5% in patients with stroke or TIAs and with the recent utilization of CTA in those patients presenting acutely the prevalence has gone up to almost 3.2% [ 9 - 12 ].…”

Clinical implications of the incidental finding of a free‐floating thrombus in the internal carotid artery

“…FFT constitute a rare, but known, cause of cerebral ischemia. The prevalence of FFT is described at about 1.5% to 1.6% in stroke or transient ischemic attack (TIA) patients . Carotid artery ultrasonography is not only of importance for a first diagnosis, but furthermore provides an ideal monitoring method .…”

“…Despite this high short‐term morbidity and mortality, a therapeutic gold standard has not been established: There are several studies, including a recent prospective work and a meta‐analysis, as well as case reports on medical, surgical, and interventional approaches without a clear superiority regarding the clinical outcome. Inter alia, there are reports of different types of antiplatelet therapy including aspirin, clopidogrel, and ticlopidine, anticoagulation by either heparin, enoxaparin, dalteparin, or warfarin, off‐label uses of dabigatran or apixaban, surgical thrombectomy, and interventional stent‐retriever maneuvers (Table ). Based on the infrequency of description, none of these studies particularly addresses incidental findings but rather focus on symptomatic patients admitted to hospital for stroke or TIA.…”

“…Few data are available on the natural course of an FFT . Besides detachment with distal embolization, a spontaneous re‐adhesion or resolution have been discussed in the literature .…”

Ongoing uncertainties in antithrombotic management of the “hot carotid”

“…4 Another important source of uncertainty was what to do in the presence of an intraluminal thrombus associated with the stenosis. 5 In a prospective cohort study involving 61 patients with acute stroke or transient ischemic attack and intraluminal thrombi in the cervicocephalic arteries, participants were variably treated with heparin (36%), clopidogrel (25%) or lowmolecular-weight heparin (23%).…”