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Ischemic stroke
Original research
Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization
  1. Derrek Schartz1,2,
  2. Stephen Susa2,
  3. Nathaniel Ellens2,
  4. Sajal Medha K Akkipeddi2,
  5. Clifton Houk2,
  6. Tarun Bhalla2,
  7. Thomas Mattingly2,
  8. David Hasan3,
  9. Matthew T Bender2
  1. 1Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
  2. 2Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
  3. 3Neurosurgery, Duke University, Durham, North Carolina, USA
  1. Correspondence to Dr Derrek Schartz, Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA; derrek_schartz{at}urmc.rochester.edu

Abstract

Background Carotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization and/or intracranial hemorrhage (ICH) may still occur.

Methods All patients with symptomatic ILT from 2016 to 2023 were identified from our tertiary care institution. Patients with MM failure (recurrent cerebral ischemia and/or symptomatic ICH) were compared with patients with MM non-failure. Differences in ILT volume and length were calculated. Receiver operator characteristic (ROC) curve analysis was used to identify the cut-off volume and length for risk of MM failure.

Results In total, 45 patients with ILT were identified with 41 treated with frontline MM. Of these 41 patients treated with MM, seven (17%) had MM failure with six (14.6%) having new embolic stroke and one (2.3%) with symptomatic ICH. Patients with MM failure had a significantly higher mean thrombus volume than MM non-failure patients (257 mm3 vs 59.6 mm3, P=0.0006). Likewise, patients with MM failure had significantly longer thrombus on average (21 mm vs 6.6 mm, P=0.0009). ROC curve analysis showed that an ILT volume of 90 mm3 resulted in a sensitivity of 71.4% and specificity of 85.3% for MM failure (AUC 0.775; CI 0.55 to 1.0, P=0.023).

Conclusions Carotid ILTs that fail MM are significantly larger and longer. These findings suggest that a thrombus volume of 90 mm3 may serve as a guide for intervention with good sensitivity and specificity for risk of MM failure.

  • stroke
  • artery
  • embolic
  • cervical

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2023-021044

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Twitter @D_SchartzMD, @SajalAkkipeddi

    • Contributors Conception and design: DS, NE, TM, MTB. Data acquisition: DS, SS. Data analysis: DS. Interpretation of data: All authors. Primary manuscript writing: DS, MTB. Manuscript editing and appraisal: All authors. DS and MTB are guarantors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.