Symptomatic patients with intraluminal carotid artery thrombus: outcome with a strategy of initial anticoagulation

Abstract

Object: The aim of this study was to define the optimal treatment for patients with symptomatic intraluminal carotid artery thrombus (ICAT).

Methods: The authors performed a retrospective chart review of patients who had presented with symptomatic ICAT at their institution between 2001 and 2011.

Results: Twenty-four patients (16 males and 8 females) with ICAT presented with ischemic stroke (18 patients) or transient ischemic attack ([TIA], 6 patients). All were initially treated using anticoagulation with or without antiplatelet drugs. Eight of these patients had no or only mild carotid artery stenosis on initial angiography and were treated with medical management alone. The remaining 16 patients had moderate or severe carotid stenosis on initial angiography; of these, 10 underwent delayed revascularization (8 patients, carotid endarterectomy [CEA]; 2 patients, angioplasty and stenting), 2 refused revascularization, and 4 were treated with medical therapy alone. One patient had multiple TIAs despite medical therapy and eventually underwent CEA; the remaining 23 patients had no TIAs after treatment. No patient suffered ischemic or hemorrhagic stroke while on anticoagulation therapy, either during the perioperative period or in the long-term follow-up; 1 patient died of an unrelated condition. The mean follow-up was 16.4 months.

Conclusions: Results of this study suggest that initial anticoagulation for symptomatic ICAT leads to a low rate of recurrent ischemic events and that carotid revascularization, if indicated, can be safely performed in a delayed manner.

Figure 1

Intraluminal Carotid Thrombus (Case 3). A 60 year old male presented with multiple TIAs. Digital subtraction angiography (DSA) revealed 80% stenosis of the right internal carotid artery and an intraluminal carotid thrombus (ICT) (black arrow) distal to the stenosis (Fig 1A). Anticoagulant therapy was administered for 29 days. He did not experience any ischemic events in the interim. Follow up DSA demonstrated complete resolution of the ICT and 80% residual carotid stenosis (Fig 1B). The patient subsequently underwent carotid endarterectomy. There were no new ischemic events over 87 weeks of follow up.