Spontaneous Resolution of Carotid Stenosis with Free Floating Thrombus: A Brief Overview of Possible Mechanisms and Management

Free floating thrombus is uncommon in the carotid arteries, and it is defined as an elongated thrombus attached to the arterial wall with circumferential blood flow at its distal most aspect. The majority of patients present with acute neurological deficits and usually have an underlying unstable atherosclerotic plaque. We present two cases of carotid stenosis associated with free floating thrombus. Both patients shared similar clinical presentation and were managed according to the standard workflow for suspected ischemic strokes from our institution. Conservative management was decided based on a multidisciplinary decision that intervention of any kind would be associated with high risk of periprocedural complications. Complete resolution of the atherosclerotic plaque and free floating thrombus in a short period occurred. We further discuss the mechanism behind such a dramatic radiographic and clinical improvement with medical therapy, hypothesizing that plaque erosion is a plausible explanation, based on pathology studies.