To describe the case of a patient with a carotid floating thrombus successfully treated with newer oral anticoagulants.

Carotid floating thrombus are uncommonly encountered, and therefore have seldom been thoroughly studied, which makes treatment difficult, as guidelines and clinical trials are lacking. 

Case report.

A 69 year-old with history of untreated diabetes and hypertension presents to the emergency department 5 hours after sudden-onset right-sided hemiparesis, non-fluent aphasia and homonimus hemianopia; NIHSS was 14. MRI showed a subacute stroke in the territories of the left middle cerebral and anterior choroidal artery. On Etiological evaluation, atrial fibrillation was found in 24 hour ECG monitoring; transesophageal echocardiography revealed a thrombus in the left atrial appendage. Carotid doppler ultrasound showed a 70% occlusion in the left internal carotid, with hemodynamic repercussions. Contrast-enhanced angioCT shows a floating thrombus, extending from carotid bifurcation to the intrapetrosal segment. Due to high risk of distal embolization, endarterectomy was delayed, and apixaban started (5mg twice-daily). A control angioCT is performed 96 hours later without evidence of luminal thrombus. Although there was no neurological deterioration (NIHSS 13), MRI was repeated, without evidence of new infarcts. Incidentally, the patient was found to have a pituitary prolactinoma, papillary thyroid neoplasia and hepatic cyst.

Newer oral anticoagulants are a viable alternative for floating thrombus, further studies are needed, although the scarcity of cases makes reporting individual or serial cases ever more necessary.