Neurointervention.  2020 Nov;15(3):144-153. 10.5469/neuroint.2020.00087.

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

• Al-Jehani H
• Alhamid MA
• Alkhalaf Y
• Alabbas F

• KMID: 2508067
• DOI: http://doi.org/10.5469/neuroint.2020.00087

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.

Keyword

Free-floating thrombus; Vertebral artery; Middle cerebral artery; Acute ischemic stroke; Thrombectomy

Figure

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  Fig. 1. Magnetic resonance imaging brain showing the sizable right middle cerebral artery (MCA) territory ischemic stroke on FLAIR imaging (upper panel). The magnetic resonance angiography shows the occlusion of the superior branch of the right MCA (lower panel).

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  Fig. 2. Computed tomography angiography with axial and sagittal demonstration of the free-floating thrombus in the right vertebral artery at the junction of the V3-4 segment. R, right; L, left.

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  Fig. 3. Diagnostic and interventional angiogram. (A) Left vertebral angiographic run showing no cross flow into the right vertebral artery. (B) The right vertebral angiographic run showing the filling defect of the free-floating thrombus (FFT) with minimal contrast flow into the distal vertebral artery. (C) The aspirated fragments of the FFT. (D) Right vertebral angiographic run post contact aspiration showing no flow limitation in the vertebral artery with mild stenosis at the V3-4 junction with sluggish flow in the right posterior-inferior cerebellar artery.

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  Fig. 4. Post thrombectomy diffusion weighted magnetic resonance imaging showing no ischemic event in the posterior circulation territory.

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  Fig. 5. A proposed practical approach to free-floating thrombus (FFT). CEA, carotid endarterectomy; EVT, endovascular therapy.

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