Abstract
BACKGROUND: Carotid free-floating thrombi (CFFT) are uncommon but pose a high risk of embolic stroke. While vascular intervention is often favored, this case study demonstrates the potential of short-term anticoagulation, guided by thorough imaging, as an alternative treatment strategy. CASE PRESENTATION: We present a patient with an acute ischemic stroke (NIHSS 15) due to middle cerebral artery (MCA) occlusion. Intravenous alteplase successfully revascularized the MCA. However, subsequent imaging revealed a CFFT as the likely source of the occlusion. Rather than immediate surgical intervention, we opted for a treatment strategy guided by comprehensive radiological assessments, including high-resolution MRI and serial ultrasounds. These assessments suggested the thrombus was newly formed. Based on this, we hypothesized it would be responsive to anticoagulation. Indeed, short-term enoxaparin therapy resulted in significant resolution of the CFFT. CONCLUSIONS: This case highlights the efficacy of anticoagulation for treating newly formed CFFT, suggesting a potential alternative to immediate intervention when guided by detailed radiological evaluation. This case introduces a novel approach that may expand treatment options for this challenging condition.