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<!DOCTYPE html><html lang="en"><head><meta charSet="utf-8"/><meta name="viewport" content="width=device-width, initial-scale=1"/><link rel="preload" as="image" href="/_next/static/media/logo-bmj-journals.4304841c959cf8fd7fd20a61cc63fe89.svg" /><link rel="preload" as="image" href="/next-resources/logo.svg" /><link rel="preload" as="image" href="/next-resources/search.svg" /><link rel="preload" as="image" href="/next-resources/hamburger-menu.svg" /><link rel="preload" as="image" href="https://resources.bmj.com/repository/journals-network-project/images/social-media/rss.svg" /><link rel="preload" as="image" href="https://resources.bmj.com/repository/journals-network-project/images/social-media/x.svg" /><link rel="preload" as="image" href="/_next/static/media/bmj-footer-logo.c6e1ad28003cb22dbd978555514ed05c.svg" /><link rel="preload" as="image" href="/next-resources/vector.svg" /><link rel="preload" as="image" href="/next-resources/download-pdf.svg" /><link rel="preload" as="image" href="/next-resources/orcid-logo.svg" /><link rel="stylesheet" href="/_next/static/css/831b189689f7769b.css" data-precedence="next" /><link rel="stylesheet" href="/_next/static/css/5631360f3b43f25f.css" data-precedence="next" /><link rel="stylesheet" href="/_next/static/css/66ad511738c93f8a.css" data-precedence="next" /><link rel="preload" as="script" fetchPriority="low" href="/_next/static/chunks/webpack-8279bfe1e5fb5dfc.js" /><script src="/_next/static/chunks/1dd3208c-9d76d526575ccb40.js" async=""></script><script src="/_next/static/chunks/286-f34bccc04707da60.js" async=""></script><script src="/_next/static/chunks/main-app-ea968dc5e14e4750.js" async=""></script><script src="/_next/static/chunks/9af238c7-d9f324d096f5b01b.js" async=""></script><script src="/_next/static/chunks/22747d63-7f124ab79e18b585.js" async=""></script><script src="/_next/static/chunks/599-bd5c02f387837b4d.js" async=""></script><script src="/_next/static/chunks/789-19b4cf9884ba70ce.js" async=""></script><script src="/_next/static/chunks/97-bac2b3d00341ccba.js" async=""></script><script src="/_next/static/chunks/345-217f92e4288d4463.js" async=""></script><script src="/_next/static/chunks/app/content/%5Bvolume%5D/%5Bissue%5D/%5BarticleId%5D/page-e3b80c9ca7d1421e.js" async=""></script><script src="/_next/static/chunks/633-8ab650060db62dad.js" async=""></script><script src="/_next/static/chunks/app/error-6385b16259b1ee68.js" async=""></script><link rel="preload" href="https://cookie-cdn.cookiepro.com/scripttemplates/otSDKStub.js" as="script" /><link rel="preload" href="https://securepubads.g.doubleclick.net/tag/js/gpt.js" as="script" /><link rel="preload" as="image" href="/next-resources/mail.svg" /><link rel="preload" as="image" href="/next-resources/tooltip.svg" /><link rel="preload" as="image" href="/next-resources/circle-arrow-up.svg" /><link rel="preload" as="image" href="/next-resources/open-url-for-metrics.svg" /><link rel="shortcut icon" href="/next-resources/favicon.ico" type="image/vnd.microsoft.icon" /><link rel="preconnect dns-prefetch" href="https://securepubads.g.doubleclick.net" /><link rel="preload" href="https://securepubads.g.doubleclick.net/tag/js/gpt.js" as="script" /><link rel="preconnect dns-prefetch" href="https://analytics.bmj.com" /><link rel="preconnect dns-prefetch" href="https://cdn-eu.pagesense.io" /><link rel="preconnect dns-prefetch" href="https://popup.wisepops.com" /><link rel="preconnect dns-prefetch" href="https://www.medtargetsystem.com" /><link rel="preload" href="https://cookie-cdn.cookiepro.com/scripttemplates/otSDKStub.js" as="script" /><title>Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort | Stroke and Vascular Neurology</title><meta name="description" content="Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."/><meta name="DC.Contributor" content="Dar Dowlatshahi"/><meta name="DC.Contributor" content="Cheemun Lum"/><meta name="DC.Contributor" content="Bijoy K Menon"/><meta name="DC.Contributor" content="Aditya Bharatha"/><meta name="DC.Contributor" content="Prasham Dave"/><meta name="DC.Contributor" content="Paulo Puac-Polanco"/><meta name="DC.Contributor" content="Dylan Blacquiere"/><meta name="DC.Contributor" content="Grant Stotts"/><meta name="DC.Contributor" content="Michel Shamy"/><meta name="DC.Contributor" content="Franco Momoli"/><meta name="DC.Contributor" content="Rebecca Thornhill"/><meta name="DC.Contributor" content="Ronda Lun"/><meta name="DC.Contributor" content="Carlos Torres"/><meta name="DC.Format" content="text/html"/><meta name="DC.Identifier" content="10.1136/svn-2022-001639"/><meta name="DC.Language" content="en"/><meta name="DC.Publisher" content="BMJ Publishing Group Ltd"/><meta name="DC.AccessRights" content="open-access"/><meta name="DC.Title" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta name="DC.Description" content="Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."/><meta name="DC.Date" content="2023-06-23"/><meta name="DC.Type" content="journal-article"/><meta name="DC.Rights" content="This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license"/><meta name="citation_title" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta name="citation_abstract" content="Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."/><meta name="citation_journal_title" content="Stroke and Vascular Neurology"/><meta name="citation_publisher" content="BMJ Publishing Group Ltd"/><meta name="citation_publication_date" content="2023-06-23"/><meta name="citation_volume" content="8"/><meta name="citation_issue" content="3"/><meta name="citation_doi" content="10.1136/svn-2022-001639"/><meta name="citation_mjid" content="svnbmj;8/3/null"/><meta name="citation_id" content="8/3/null"/><meta name="citation_public_url" content="https://svn.bmj.com/content/8/3/194"/><meta name="citation_full_html_url" content="https://svn.bmj.com/content/8/3/194"/><meta name="citation_pdf_url" content="https://svn.bmj.com/content/8/3/194.full.pdf"/><meta name="citation_issn" content="2059-8696"/><meta name="citation_journal_abbrev" content="Stroke Vasc Neurol"/><meta name="citation_pmid" content="10.1136/svn-2022-001639"/><meta name="citation_article_type" content="research-article"/><meta name="citation_section" content="Original research"/><meta name="citation_access" content="open-access"/><link rel="canonical" href="/content/8/3/194" /><link rel="alternate" type="application/pdf" href="/content/8/3/194.full.pdf" /><meta property="og:title" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta property="og:description" content="Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."/><meta property="og:url" content="https://svn.bmj.com/content/8/3/194"/><meta property="og:site_name" content="Stroke and Vascular Neurology"/><meta property="og:locale" content="en_GB"/><meta property="og:image" content="https://bmjjournals-chicken.bmj.com/wp-content/uploads/2022/04/94bm3OnO_400x400-1.jpeg"/><meta property="og:image:width" content="800"/><meta property="og:image:height" content="600"/><meta property="og:image:alt" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta property="og:image" content="https://bmjjournals-chicken.bmj.com/wp-content/uploads/2022/04/94bm3OnO_400x400-1.jpeg"/><meta property="og:image:width" content="1800"/><meta property="og:image:height" content="1600"/><meta property="og:image:alt" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta property="og:type" content="website"/><meta name="twitter:card" content="summary_large_image"/><meta name="twitter:site" content="@bmj_latest"/><meta name="twitter:title" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta name="twitter:description" content="Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."/><meta name="twitter:image" content="https://bmjjournals-chicken.bmj.com/wp-content/uploads/2022/04/94bm3OnO_400x400-1.jpeg"/><meta name="twitter:image:alt" content="Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort"/><meta name="citation_author"/><meta name="citation_author_institution"/><meta name="citation_reference" content="citation_journal_title=Stroke;citation_author=R-J. Singh;citation_author=D. Chakraborty;citation_author=S. Dey;citation_title=Intraluminal thrombi in the Cervico-Cephalic arteries;citation_pages=357-64;citation_volume=50;citation_year=2019;citation_pmid=http://www.n;citation_doi=10.1161/STROKEAHA.118.023015"/><meta name="citation_reference" content="citation_journal_title=Int J Stroke;citation_author=S. Fridman;citation_author=SP. Lownie;citation_author=J. Mandzia;citation_title=Diagnosis and management of carotid free-floating thrombus: a systematic literature review;citation_pages=247-56;citation_volume=14;citation_year=2019;citation_pmid=http://www.n"/><meta name="citation_reference" content="citation_journal_title=Annals of vascular surgery;citation_journal_abbrev=Ann Vasc Surg;citation_author=J. Combe;citation_author=P. Poinsard;citation_author=J. Besancenot;citation_title=Free-floating thrombus of the extracranial internal carotid artery.;citation_pages=558-562;citation_volume=4;citation_year=1990;citation_issue=6;citation_pmid=2261324;citation_doi=10.1016/S0890-5096(06)60839-X"/><meta name="citation_reference" content="citation_journal_title=Stroke;citation_journal_abbrev=Stroke;citation_author=A. Buchan;citation_author=P. Gates;citation_author=D. Pelz;citation_title=Intraluminal thrombus in the cerebral circulation. Implications for surgical management;citation_pages=681-687;citation_volume=19;citation_year=1988;citation_issue=6;citation_pmid=3376159;citation_doi=10.1161/01.STR.19.6.681"/><meta name="citation_reference" content="citation_journal_title=Neurology;citation_author=C. Torres;citation_author=C. Lum;citation_author=P. Puac-Polanco;citation_title=Differentiating carotid free-floating thrombus from atheromatous plaque using intraluminal filling defect length on cta: a validation study;citation_pages=e785-93;citation_volume=97;citation_year=2021;citation_pmid=http://www.n"/><meta name="citation_reference" content="citation_journal_title=Neuroradiology;citation_author=A. Jaberi;citation_author=C. Lum;citation_author=P. Stefanski;citation_title=Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus;citation_pages=15-23;citation_volume=56;citation_year=2014;citation_pmid=http://www.n"/><meta name="citation_reference" content="citation_journal_title=Can J Neurol Sci;citation_author=DJ. Gladstone;citation_author=MP. Lindsay;citation_author=J. Douketis;citation_title=Canadian stroke best practice recommendations: secondary prevention of stroke update 2020;citation_pages=315-37;citation_volume=49;citation_year=2022;citation_pmid=http://www.n;citation_doi=10.1017/cjn.2021.127"/><meta name="citation_reference" content="citation_journal_title=International Journal of Stroke;citation_journal_abbrev=Int J Stroke;citation_author=EP. Johansson;citation_author=C. Arnerlöv;citation_author=P. 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Institute, Ottawa, Ontario, Canada"},{"@type":"Organization","name":"School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Cheemun Lum","affiliation":[{"@type":"Organization","name":"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Bijoy K Menon","affiliation":[{"@type":"Organization","name":"Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada"}]},{"@type":"Person","name":"Aditya Bharatha","affiliation":[{"@type":"Organization","name":"Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada"}]},{"@type":"Person","name":"Prasham Dave","affiliation":[{"@type":"Organization","name":"Medicine, Queen's University, Kingston, Ontario, Canada"}]},{"@type":"Person","name":"Paulo Puac-Polanco","affiliation":[{"@type":"Organization","name":"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Dylan Blacquiere","affiliation":[{"@type":"Organization","name":"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Grant Stotts","affiliation":[{"@type":"Organization","name":"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Michel Shamy","affiliation":[{"@type":"Organization","name":"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada"},{"@type":"Organization","name":"Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"},{"@type":"Organization","name":"School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Franco Momoli","affiliation":[{"@type":"Organization","name":"School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Rebecca Thornhill","affiliation":[{"@type":"Organization","name":"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Ronda Lun","affiliation":[{"@type":"Organization","name":"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada"}]},{"@type":"Person","name":"Carlos Torres","affiliation":[{"@type":"Organization","name":"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada"}]}],"abstract":"Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.","datePublished":"2023-06-23","isPartOf":{"@type":"PublicationIssue","issueNumber":"3","pagination":"","isPartOf":{"@type":"PublicationVolume","volumeNumber":"8","isPartOf":{"@type":"Periodical","name":"Stroke and Vascular Neurology"}}},"url":"https://svn.bmj.com/content/8/3/194","description":"WHAT IS ALREADY KNOWN ON THIS TOPIC Carotid free-floating thrombi (FFT) are high risk for stroke recurrence."}</script><div><div class="navbar transform-translate-y-full top-[8rem] opacity-0 bg-bmj-white/30 fixed z-10 w-full backdrop-blur-md transition-transform duration-300 ease-in-out" data-testid="floating-bar"><div class="progress-bar bg-bmj-blue-600 block h-[2px]" style="width:0%"></div></div><div class="bg-white"><div class="mb-[24px] flex justify-between bg-white pt-2 md:mb-10"><div><div data-testid="breadcrumbs" class="px-4"><span class="text-bmj-font-color-medium 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class="inline"><span data-testid="author-list-name-8" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Michel Shamy</span><sup class="ml-1 inline">1 2 3</sup></span></p></button>,</span><span class="mr-[4px]"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rqipmpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus-visible:border-bmj-article-oa-tag focus-visible:text-bmj-blue-600 not-prose text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]" tabindex="90"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-900 not-prose group text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-9" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Franco Momoli</span><sup class="ml-1 inline">3</sup></span></p></button>,</span><span class="mr-[4px]"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rripmpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus-visible:border-bmj-article-oa-tag focus-visible:text-bmj-blue-600 not-prose text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]" tabindex="90"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-900 not-prose group text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-10" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Rebecca Thornhill</span><sup class="ml-1 inline">4</sup></span></p></button>,</span><span class="mr-[4px]"><button type="button" aria-haspopup="dialog" aria-expanded="false" 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focus-visible:border-bmj-article-oa-tag w-full rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]" tabindex="60"><span data-testid="share-text" class="bg-bmj-blue-600 hover:bg-bmj-blue-700 active:bg-bmj-blue-800 block h-[44px] w-full rounded-lg md:hidden"><span class="focus-visible:border-bmj-article-oa-tag flex h-full items-center justify-center text-sm font-bold leading-6 text-white focus-visible:border-[1px] focus-visible:outline-none">Article options</span></span><span class="share-cite-rights-tooltip bg-share-icon-bg focus-visible:border-bmj-article-oa-tag hidden h-[44px] w-[44px] rounded-[8px] pb-[12px] pl-[16px] pr-[16px] pt-[12px] focus-visible:border-[1px] focus-visible:outline-none md:block lg:block"><img src="/next-resources/tooltip.svg" alt="Tooltip icon" class="m-auto h-full" /></span></button></div></div><div class="grid grid-cols-[3fr_1fr] gap-x-4 gap-y-4 md:grid-cols-[auto_332px]"><div class="col-span-2 mb-2 md:mb-6 lg:col-span-1 pt-[24px]"><div><div xmlns="http://www.w3.org/1999/xhtml" class="article fulltext-view flex flex-col -mb-6"><div class="abstract-section" id="abstract-1"><h2>Abstract</h2><div id="sec-1" class="subsection"><p id="p-2"><strong>Background</strong> Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.</p></div><div id="sec-2" class="subsection"><p id="p-3"><strong>Methods</strong> We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.</p></div><div id="sec-3" class="subsection"><p id="p-4"><strong>Results</strong> We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.</p></div><div id="sec-4" class="subsection"><p id="p-5"><strong>Conclusions</strong> The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.</p></div><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div><div class="section notes text-bmj-silver-800 border-bmj-silver-100 rounded-lg [&_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [&_p]:my-[8px] [&_li]:m-0 [&_li]:p-0 [&_h3]:mb-0 [&_h3]:mt-[10px] [&_h3]:text-[1.25rem] [&_h3]:font-normal"><div data-testid="article-notes-content" class="article-notes-content"><div class="" id="boxed-text-1"><h3 data-testid="article-notes-subheader">What is already known on this topic</h3><ul class="list-unord " id="list-1"><li id="list-item-1"><p id="p-6">Carotid free-floating thrombi (FFT) are high risk for stroke recurrence.</p></li><li id="list-item-2"><p id="p-7">Carotid FFT are associated with local plaque rupture.</p></li></ul><div id="sec-5" class="subsection"><h3>What this study adds</h3><ul class="list-unord " id="list-2"><li id="list-item-3"><p id="p-8">Up to 40% of carotid FFT have associated stenosis requiring revascularisation.</p></li><li id="list-item-4"><p id="p-9">Up to 20% of carotid FFT have a non-atherosclerotic aetiology.</p></li></ul></div><div id="sec-6" class="subsection"><h3>How this study might affect research, practice or policy</h3><ul class="list-unord " id="list-3"><li id="list-item-5"><p id="p-10">Carotid FFT require investigation for non-atherosclerotic aetiologies.</p></li></ul></div></div></div></div><div id="middle-ad-slot-1" class="block md:hidden"><div class="block"><div id="div-gpt-ad-1686906823508-1-parent" data-testid="middle-ad-slot-1-parent" class="flex items-center justify-center py-3 undefined mb-[30px] md:mb-[30px] pt-0 md:pt-0 undefined undefined undefined"><div id="div-gpt-ad-1686906823508-1" data-testid="middle-ad-slot-1" class="flex items-center justify-center w-[300px] h-[250px] md:h-[600px]"></div></div></div></div><div class="article-body-sections wrap-urls pb-[24px]" data-testid="article-body-section"><section id="sec-7"><h2 class="">Introduction</h2><p id="p-11">Carotid free-floating thrombi (FFT) are present in 1.6%–3.7% of patients presenting with acute transient ischaemic attack (TIA)/stroke.<a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a> While relatively uncommon, FFT are high-risk lesions with an approximately 11% risk of stroke or death within 30 days of diagnosis.<a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a> Immediate management typically consists of antithrombotic medications,<a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a> although there is no consensus on the optimal therapeutic agent or duration of therapy.</p><p id="p-12">The majority of FFT are believed to originate from local atherosclerotic plaque rupture. Moreover, many are associated with a significant degree of underlying carotid stenosis.<a id="xref-ref-1-3" class="xref-bibr" href="#ref-1">1</a> However, FFT are also reported in association with dissections, coagulopathy and malignancy, and can be associated with cardioembolism.<a id="xref-ref-1-4" class="xref-bibr" href="#ref-1">1 3 4</a> The relative proportion of atherosclerotic versus non-atherosclerotic causes of FFT is unknown.</p><p id="p-13">Our primary objective was to explore and classify the underlying aetiology of carotid thrombi in a well-characterised consecutive, prospective, multicentre cohort of patients presenting with TIA/stroke symptoms and confirmed ipsilateral FFT. Our secondary objective was to characterise the degree of underlying stenosis when the FFT was associated with local atherosclerotic plaque.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div><div class="article-body-sections wrap-urls pb-[24px]" data-testid="article-body-section"><section id="sec-8"><h2 class="">Methods</h2><p id="p-14">We prospectively enrolled consecutive patients presenting to the emergency departments of the Ottawa Hospital (Ottawa, Canada), Calgary Foothills Hospital (Calgary, Canada) and St. Michael’s Hospital (Toronto, Canada) with a diagnosis of acute TIA/stroke within 24 hours of symptom onset. Details of the study (ClinicalTrials.gov <a href="https://clinicaltrials.gov/study/NCT02405845" target="_blank" rel="noreferrer">NCT02405845</a>) are published elsewhere.<a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a> Patients were enrolled if the CT angiography (CTA) at presentation revealed an ipsilateral internal carotid artery (ICA) lesion suspected to represent an FFT, based on the appearance of an intraluminal filling defect. Diagnosis of FFT was confirmed by either the resolution or decrease in size of the filling defect seen on serial CTA, based on consensus review by two neuroradiologists, or intraoperative pathology during carotid endarterectomy. Antithrombotic therapy and the timing of repeat clinical CTAs were at the discretion of the treating physician. In patients where no resolution or decrease in size of the filling defect was observed on CTAs in the first month, a CTA was performed at 5 weeks following symptom onset, as per study protocol; if the lesion was unchanged on this repeat CTA, it was deemed not to be FFT. The threshold of 5 weeks was chosen a priori based on prior work demonstrating that all confirmed FFT decreased in size within 3 weeks of symptom onset.<a id="xref-ref-6-1" class="xref-bibr" href="#ref-6">6</a> </p><p id="p-15">The aetiology of FFT was determined based on imaging appearance and medical record review as: (1) carotid atherosclerotic disease if there was residual plaque identified on follow-up CTA imaging directly adjacent to, or in contact with the filling defect after FFT resolution, and with no other potential cause identified; (2) carotid dissection; (3) cardioembolism if no adjacent plaque or dissection was identified after resolution and cardiac testing revealed atrial fibrillation or any other known cardiac source; (4) possible carotid atherosclerosis or cardioembolism where both adjacent plaque and a known cardiac source were discovered or (5) embolic stroke of uncertain source (ESUS) where no ipsilateral plaque was identified and aetiological testing was unrevealing. Patients with an adjacent carotid plaque were further subclassified as having ≥50% or <50% stenosis. All imaging assessments for aetiology were by consensus of two neuroradiologists. Aetiological workup followed the Canadian Best Practice Recommendations<a id="xref-ref-7-1" class="xref-bibr" href="#ref-7">7</a> and included cardiac transthoracic echocardiography and ambulatory rhythm monitoring for 14 days to assess for atrial fibrillation. After completing the initial prospective study, a medical record review was conducted for any additional aetiological workup. Source data will be available on reasonable request to the lead investigators.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div><div class="article-body-sections wrap-urls pb-[24px]" data-testid="article-body-section"><section id="sec-9"><h2 class="">Results</h2><p id="p-16">We enrolled 100 patients with suspected FFT: 1 subject withdrew consent and 4 were excluded from the study due to protocol deviations (3 patients did not have a repeat CTA to confirm FFT, and 1 patient was erroneously enrolled with a vertebral artery thrombus). Detailed information on the full study cohort is published elsewhere.<a id="xref-ref-5-2" class="xref-bibr" href="#ref-5">5</a> Eighty-three patients had confirmed FFT on follow-up imaging (median confirmatory follow-up scan at 4 days) and were included in our analysis (<a id="xref-table-wrap-1-1" class="xref-table" href="#T1">table 1</a>). Two patients experienced recurrent events: one TIA and one stroke requiring thrombectomy.<a id="xref-ref-5-3" class="xref-bibr" href="#ref-5">5</a> </p><div class="border-bmj-silver-50 my-[40px] w-full border-b border-t" data-testid="table-component" id="T1"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 1</strong><div class="my-2 flex gap-[4px] content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="text-[12px] leading-[16px] visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 outline-none focus-visible:rounded-md underline focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]">View inline</button><span class="text-bmj-blue-600 mt-[3px] leading-5 text-[8px]">•</span><button class="text-[12px] leading-[16px] visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 outline-none focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] focus-visible:rounded-md underline" data-testid="popup-open-button" id="table-popup-open-button-null">Open as popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Baseline characteristics of patients confirmed to have a carotid free-floating thrombus</div></div><p id="p-18">Aetiological assessment revealed that 66/83 (79.5%) patients had an underlying adjacent atherosclerotic plaque. Another 10/83 (12%) had both atrial fibrillation and adjacent atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 3/83 (3.6%) were classified as ESUS and no patient had atrial fibrillation in the absence of adjacent plaque. Of the 76 patients with adjacent atherosclerotic disease (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis (details in <a id="xref-supplementary-material-1-1" class="xref-supplementary-material" href="#DC1">online supplemental table 1</a>). Of the four patients classified as ESUS, one was a 25-year-old patient with patent foramen ovale, and two were suspected of having hypercoagulability (one due to lung carcinoma and one related to ulcerative colitis).</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div><div class="article-body-sections wrap-urls pb-[24px]" data-testid="article-body-section"><section id="sec-10"><h2 class="">Discussion</h2><p id="p-20">These results show that atherosclerotic plaque rupture may be the likely aetiology in at least four out of every five patients presenting with FFT and TIA/stroke. This number could be higher if it is assumed that FFT is due to plaque rupture in patients with a coexisting aetiology, that is, with both atrial fibrillation and local atherosclerotic plaque. Moreover, over half of these patients had underlying carotid stenoses of ≥50% warranting urgent revascularisation, which is comparable to a recent single-centre cohort study.<a id="xref-ref-1-5" class="xref-bibr" href="#ref-1">1</a> These findings highlight an important knowledge gap in FFT management in the context of symptomatic carotid stenosis: should such patients be offered early revascularisation, or should there be a period of antithrombotic therapy to reduce thrombus burden prior to either endarterectomy or carotid artery stenting? Immediate treatment with the combination of anticoagulation and antiplatelet therapy is associated with partial or complete resolution of FFT in 75%–86.5% of patients within a median time of 4–6 days.<a id="xref-ref-1-6" class="xref-bibr" href="#ref-1">1 5</a> This must be weighed against the early recurrent stroke risk associated with delaying revascularisation for symptomatic carotid stenosis, which can be as high as 7.9% in the first week.<a id="xref-ref-8-1" class="xref-bibr" href="#ref-8">8</a> These two approaches may warrant further study in a comparative randomised trial.</p><p id="p-21">Between 8% and 20% of patients presenting with FFT have a non-atherosclerotic aetiology in this study (with the higher number of this range based on the assumption that those with both atrial fibrillation and atherosclerosis were the result of cardio-embolism). Approximately 5% of these FFTs were secondary to carotid dissections in the acute setting, but the remaining FFTs required additional investigations to identify other aetiologies (arrhythmias, malignancies and other causes of hypercoagulability). This suggests that up to 15% of FFTs may result from a process distant from the carotid artery. Furthermore, approximately 1 of every 25 patients met the criteria for ESUS, highlighting the need for vigilance and additional investigations in the setting of FFT.</p><p id="p-22">The strengths of our study include the study protocol-specified prospective consecutive enrolment, the validated FFT diagnostic criteria and the multicentre recruitment. But our study has important limitations. While atrial fibrillation was either known or discovered in 12% of patients, it is possible that its prevalence as an aetiology of FFT was underestimated. Conversely, local plaque rupture could also be underestimated as atheromatous changes below the detection threshold of CTA or atheroma proximal to the ICA could also give rise to FFT. For these reasons, we believe the estimates for FFT aetiology are likely to range from 80% to 92% for local plaque rupture and up to 16% for cardioembolism. Finally, our study did not collect information around the management of underlying carotid stenosis, therefore, we were not able to assess how the presence of FFT affected revascularisation decisions.</p><p id="p-23">In summary, the majority of symptomatic carotid artery FFT are caused by local atherosclerotic plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, FFT are also caused by non-atherosclerotic mechanisms warranting additional investigations for cardioembolism, hypercoagulability and malignancy. Where significant carotid stenosis is found with FFT, it is unclear whether urgent revascularisation or medical management is best to resolve FFT.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div><section id="supplementary-materials" class="article-body-sections order-2 mb-0"><div data-testid="accordion-wrapper" class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><div data-testid="accordion-toggle-button" class="w-full" data-orientation="vertical"><div data-state="closed" data-orientation="vertical"><h3 data-orientation="vertical" data-state="closed" class="flex"><button type="button" aria-controls="radix-:R1e2rmpuuuuuj4ja:" aria-expanded="false" data-state="closed" data-orientation="vertical" id="radix-:Re2rmpuuuuuj4ja:" 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DD, CT and CL provided supervision. DD is the guarantor of the overall content.</p></li><li class="fn-other" id="fn-2"><p id="p-25"><span class="fn-label font-bold">Funding:</span> This study was funded by uOttawa Department of Medicine.</p></li><li class="fn-conflict" id="fn-3"><p id="p-26"><span class="fn-label font-bold">Competing interests:</span> None declared.</p></li><li class="fn-other" id="fn-4"><p id="p-27"><span class="fn-label font-bold">Provenance and peer review:</span> Not commissioned; externally peer reviewed.</p></li><li class="fn-other" id="fn-5"><p id="p-28"><span class="fn-label font-bold">Supplemental material:</span> 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.</p></li></ul></div></div><div data-testid="DEA-section" class="text-bmj-silver-800 p-0"><div class="wrap-urls my-6"><p data-testid="data-availability-title" class="m-0 mb-4 text-base font-bold ">Data availability statement</p><section data-testid="data-availability-text" class="m-0"><html><head><script> window.dataLayer = window.dataLayer || []; function parseCookies() { let cookieHeader = document.cookie || ""; let cookies = Object.fromEntries( cookieHeader.split("; ").map((c) => c.split("=")) ); for (let key in cookies) { if (cookies[key] === "undefined") { cookies[key] = undefined; } } return cookies; } function uuidv4() { var d = new Date().getTime(); //Timestamp var d2 = (typeof performance !== "undefined" && performance.now && performance.now() * 1000) || 0; //Time in microseconds since page-load or 0 if unsupported return "xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx".replace(/[xy]/g, function (c) { var r = Math.random() * 16; //random number between 0 and 16 if (d > 0) { //Use timestamp until depleted r = (d + r) % 16 | 0; d = Math.floor(d / 16); } else { //Use microseconds since page-load if supported r = (d2 + r) % 16 | 0; d2 = Math.floor(d2 / 16); } return (c === "x" ? r : (r & 0x3) | 0x8).toString(16); }); } function handleCookie() { let cookies = parseCookies(); let bmj_uuid = cookies.bmj_uuid; if (!bmj_uuid) { bmj_uuid = uuidv4(); cookies.bmj_uuid = bmj_uuid; } return { bmj_uuid }; } let { bmj_uuid } = handleCookie(); let bmj_ppid = parseCookies().bmj_ppid; const anonMailId = "e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855"; let nonAnonMailId = window.dataLayer.find((item) => item.user)?.user?.mail === anonMailId ? null : window.dataLayer.find((item) => item.user)?.user?.mail; let userId = dataLayer.find((item) => item.user)?.user?.["data-ics"] ?? (dataLayer.find((item) => item.user)?.user?.mail && nonAnonMailId) ?? bmj_ppid ?? bmj_uuid; document.cookie = "bmj_ppid=" + userId + "; domain=.bmj.com; path=/; max-age=31622400; SameSite=None; Secure"; document.cookie = "bmj_uuid=" + bmj_uuid + "; domain=.bmj.com; path=/; max-age=31622400; SameSite=None; Secure"; var googletag = googletag || { cmd: [] }; googletag.cmd.push(function () { googletag.pubads().setPublisherProvidedId(userId); googletag.enableServices(); }); window.dataLayer.push({ bmj_uuid: bmj_uuid, }); </script> </head><body><div class="section data-availability" id="sec-11"><p id="p-29">Data are available on reasonable request.</p></div></body></html></section></div><div class="wrap-urls mb-6"><p data-testid="ethics-title" class="mb-4 text-base font-bold">Ethics statements</p><section class="m-0 mt-2"><section data-testid="ethics-consent-section" class="mb-[16px]">Patient consent for publication: <span data-testid="ethics-consent-text" class="font-bold"><p id="p-30" class="ethics-consent-to-publish">Not applicable.</p></span></section><section data-testid="ethics-approval-section" class="m-0">Ethics approval: <span data-testid="ethics-approval-text" class="m-0 "><p id="p-31" class="ethics-approval">This study involves human participants and was approved by REB#20150092-01H was obtained at Ottawa Health Science Network Research Ethics Board. Participants gave informed consent to participate in the study before taking part.</p></span></section></section></div></div></div><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div></div></div></div></div></div></div></div></section></section><section class="section ref-list order-1" id="ref-list-1"><section data-testid="reference-list" id="ref-list-1" class="mt-0"><div data-testid="accordion-wrapper" class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><div data-testid="accordion-toggle-button" class="w-full" data-orientation="vertical"><div data-state="closed" data-orientation="vertical"><h3 data-orientation="vertical" data-state="closed" class="flex"><button type="button" aria-controls="radix-:Rf2rmpuuuuuj4ja:" aria-expanded="false" data-state="closed" data-orientation="vertical" id="radix-:R72rmpuuuuuj4ja:" class="flex flex-1 items-center justify-between pb-[24px] transition-all text-left [&[data-state=open]>svg]:rotate-180 tracking-normal my-0 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-radix-collection-item=""><span data-testid="accordion-title" class="my-0 article-heading-text">References</span><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="h-8 w-8 shrink-0 text-muted-foreground transition-transform duration-200"><path d="m6 9 6 6 6-6"></path></svg></button></h3><div data-state="closed" id="radix-:Rf2rmpuuuuuj4ja:" role="region" aria-labelledby="radix-:R72rmpuuuuuj4ja:" data-orientation="vertical" class="overflow-hidden text-sm data-[state=closed]:animate-accordion-up data-[state=open]:animate-accordion-down data-[state=closed]:hidden" style="--radix-accordion-content-height:var(--radix-collapsible-content-height);--radix-accordion-content-width:var(--radix-collapsible-content-width)"><div class="pb-4 pt-0"><div class="text-base my-0" data-testid="accordion-content"><ol class="m-0 list-decimal" data-testid="reference-list-ol"><li data-testid="reference-item-ref-1"><div class="my-4 flex items-center" id="ref-1"><section class="relative pl-[25px] leading-[24px]"><span class="absolute left-0 h-100"><a href="#xref-ref-1-1" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 mr-[1px]" data-testid="reference-link"><img src="/next-resources/circle-arrow-up.svg" alt="close" class="inline h-[16.67px] w-[16.67px] ml-[4.38px] mt-1" data-testid="citation-arrow-img" /></a> </span><span class="text-bmj-silver-800" data-testid="author-0">Singh R-J, </span><span class="text-bmj-silver-800" data-testid="author-1">Chakraborty D, </span><span class="text-bmj-silver-800" data-testid="author-2">Dey S, </span><span data-testid="authors-etal" class="text-bmj-silver-800">et al. </span><span class="text-bmj-silver-800 wrap-urls" data-testid="reference-title">Intraluminal thrombi in the Cervico-Cephalic arteries. </span><span class="text-bmj-silver-800"><span>Stroke</span> <span>2019; 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data-testid="date-entry-first published">First Published: <strong>23 June 2023</strong></li></ul><div data-testid="links-container"></div></section><h3 class="m-0 p-0">Article versions</h3><ul class="m-0 p-0"><li class="m-0 list-none p-0"><a href="/content/early/2022/11/10/svn-2022-001639" rel="noopener noreferrer" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 table-cell underline hover:decoration-2 hover:underline-offset-2">Earlier version - 11 November 2022</a></li><li class="m-0 list-none p-0">You are viewing the most recent version of this article - 23 June 2023</li></ul><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-900 mt-[16px] rounded-md focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px] hover:underline hover:decoration-1">Back to top</button></div></div></div></div></div></div></section><section id="rapid-responses" class="article"><div data-testid="accordion-wrapper" class="wrap-urls accordion-wrapper border-bmj-silver-50 border-y"><div data-testid="accordion-toggle-button" class="w-full" data-orientation="vertical"><div data-state="closed" data-orientation="vertical"><h3 data-orientation="vertical" data-state="closed" class="flex"><button type="button" aria-controls="radix-:Rormpuuuuuj4ja:" aria-expanded="false" data-state="closed" data-orientation="vertical" id="radix-:R8rmpuuuuuj4ja:" class="flex flex-1 items-center justify-between pb-[24px] transition-all text-left [&[data-state=open]>svg]:rotate-180 tracking-normal my-0 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-radix-collection-item=""><span data-testid="accordion-title" class="my-0 article-heading-text">Responses</span><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="h-8 w-8 shrink-0 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class="text-bmj-silver-800 m-0 mb-[8px] pt-6 text-xl font-bold lg:pt-0" tabindex="-1">Overview</p><ul class="m-0 list-none p-0" data-testid="overview-list" id="overview-list"><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#abstract-1" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-1" tabindex="101">Abstract</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-7" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-2" tabindex="102">Introduction</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-8" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-3" tabindex="103">Methods</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-9" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-4" tabindex="104">Results</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-10" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-5" tabindex="105">Discussion</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#ref-list-1" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-6" tabindex="106">References</a></li><li class="px-0"><div data-testid="overview-divider" class="my-6 w-[100%] border-bmj-silver-50 border-t"></div></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#supplementary-materials" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-7" tabindex="107">Supplementary files</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#fn-group-1" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-8" tabindex="108">Footnotes</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#history-list" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-9" tabindex="109">Publication history</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#rapid-responses" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-10" tabindex="110">Responses</a></li></ul></div><div data-testid="overview-divider" class="my-6 w-[100%] 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focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-2" tabindex="102">Introduction</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-8" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-3" tabindex="103">Methods</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-9" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 no-underline hover:underline hover:decoration-1 focus-visible:outline-none focus-visible:border-bmj-article-oa-tag focus-visible:border-[1px]" data-testid="overview-list-4" tabindex="104">Results</a></li><li class="mx-0 mb-[12px] pl-0 hidden lg:block"><a href="#sec-10" class="text-bmj-blue-600 hover:text-bmj-blue-900 active:text-bmj-blue-800 leading-6 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Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a sign"])</script><script>self.__next_f.push([1,"ificant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.18:T68c,Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.19:T68c,Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy"])</script><script>self.__next_f.push([1,", malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.1a:T68c,Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. "])</script><script>self.__next_f.push([1,"The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.1b:T68c,Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiolo"])</script><script>self.__next_f.push([1,"gical assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations."])</script><script>self.__next_f.push([1,"d:[[\"$\",\"meta\",\"0\",{\"name\":\"viewport\",\"content\":\"width=device-width, initial-scale=1\"}],[\"$\",\"meta\",\"1\",{\"charSet\":\"utf-8\"}],[\"$\",\"title\",\"2\",{\"children\":\"Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort | Stroke and Vascular Neurology\"}],[\"$\",\"meta\",\"3\",{\"name\":\"description\",\"content\":\"$17\"}],[\"$\",\"meta\",\"4\",{\"name\":\"DC.Contributor\",\"content\":\"Dar Dowlatshahi\"}],[\"$\",\"meta\",\"5\",{\"name\":\"DC.Contributor\",\"content\":\"Cheemun Lum\"}],[\"$\",\"meta\",\"6\",{\"name\":\"DC.Contributor\",\"content\":\"Bijoy K Menon\"}],[\"$\",\"meta\",\"7\",{\"name\":\"DC.Contributor\",\"content\":\"Aditya Bharatha\"}],[\"$\",\"meta\",\"8\",{\"name\":\"DC.Contributor\",\"content\":\"Prasham 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Canada\"}]},{\"@type\":\"Person\",\"name\":\"Franco Momoli\",\"affiliation\":[{\"@type\":\"Organization\",\"name\":\"School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada\"}]},{\"@type\":\"Person\",\"name\":\"Rebecca Thornhill\",\"affiliation\":[{\"@type\":\"Organization\",\"name\":\"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada\"}]},{\"@type\":\"Person\",\"name\":\"Ronda Lun\",\"affiliation\":[{\"@type\":\"Organization\",\"name\":\"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada\"}]},{\"@type\":\"Person\",\"name\":\"Carlos Torres\",\"affiliation\":[{\"@type\":\"Organization\",\"name\":\"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada\"}]}],\"abstract\":\"Background Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.Methods We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.Results We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.Conclusions The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.\",\"datePublished\":\"2023-06-23\",\"isPartOf\":{\"@type\":\"PublicationIssue\",\"issueNumber\":\"3\",\"pagination\":\"\",\"isPartOf\":{\"@type\":\"PublicationVolume\",\"volumeNumber\":\"8\",\"isPartOf\":{\"@type\":\"Periodical\",\"name\":\"Stroke and Vascular Neurology\"}}},\"url\":\"https://svn.bmj.com/content/8/3/194\",\"description\":\"WHAT IS ALREADY KNOWN ON THIS TOPIC Carotid free-floating thrombi (FFT) are high risk for stroke recurrence.\"}"])</script><script>self.__next_f.push([1,"1d:T6fd,(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':\n new Date().getTime(),event:'gtm.js',...{\"page\":{\"hwTitle\":\"Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort\",\"hwUrl\":\"/content/svnbmj/8/3/194\",\"hwPath\":\"/content/svnbmj/8/3/194\",\"hwType\":\"journal-article\"},\"user\":{\"hwMemberID\":\"\",\"hwLoggedIntoInstitutionID\":\"\",\"hwLoggedIntoInstitution\":\"\",\"hwAccessUsageTerms\":\"\",\"hwRegisteredUser\":\"\",\"hwHasFullTextAccess\":\"\",\"hwEntitled\":\"\",\"mail\":\"\"},\"content\":{\"hwIssueDate\":\"2023-06-23\",\"hwIssueDateTime\":\"2023-06-23\",\"hwPublicationDate\":\"2023-06-23\",\"hwPublicationDateTime\":\"2023-06-23\",\"hwNlmArticleType\":\"\",\"hwDOI\":\"10.1136/svn-2022-001639\",\"hwAuthors\":\"Dar Dowlatshahi, Cheemun Lum, Bijoy K Menon, Aditya Bharatha, Prasham Dave, Paulo Puac-Polanco, Dylan Blacquiere, Grant Stotts, Michel Shamy, Franco Momoli, Rebecca Thornhill, Ronda Lun, Carlos Torres\",\"hwContributors\":\"\",\"hwIsEarlyRelease\":\"\",\"hwEissn\":\"\",\"hwPissn\":\"\",\"hwVolume\":\"8\",\"hwIssue\":\"3\",\"hwArticleType\":\"Original research\",\"hwTabView\":\"\",\"hwViewType\":\"\",\"hwAccessType\":\"open-access\",\"hwOpenAccess\":\"true\",\"hwFreeAccess\":\"\",\"hwTaxonomy\":\"\",\"hwCorpusCode\":\"journal\",\"hwType\":\"journal-article\",\"hwSubtitle\":null,\"hwOverline\":null,\"hwPisaId\":\"\",\"hwFirstPage\":null,\"hwLastPage\":null,\"hwIsLatestVersion\":\"\",\"hwIsCurrentIssue\":\"\",\"hwIsOpenIssue\":\"\",\"hwHasFullText\":\"\",\"hwHasPDF\":true,\"hwParentTitle\":\"\",\"hwElectronicPubDate\":\"\",\"hwElectronicPubDateTime\":\"\"}}});var f=d.getElementsByTagName(s)[0],\n j=d.createElement(s),dl=l!='dataLayer'?'\u0026l='+l:\"\";j.async=true;j.src=\n 'https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);\n })(window,document,'script','dataLayer', 'GTM-5SHSDJ');22:{\"id\":\"svnbmj\",\"title\":\"Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTim"])</script><script>self.__next_f.push([1,"estamp\":\"2023-06-23\",\"authorList\":\"Dar Dowlatshahi, Cheemun Lum, Bijoy K Menon, Aditya Bharatha, Prasham Dave, Paulo Puac-Polanco, Dylan Blacquiere, Grant Stotts, Michel Shamy, Franco Momoli, Rebecca Thornhill, Ronda Lun, Carlos Torres\",\"volume\":\"8\",\"issue\":\"3\",\"firstPage\":\"194\",\"lastPage\":\"196\"}\n23:{\"title\":\"Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort\",\"authorDisplay\":\"Dar Dowlatshahi, Cheemun Lum, Bijoy K Menon, Aditya Bharatha, Prasham Dave, Paulo Puac-Polanco, Dylan Blacquiere, Grant Stotts, Michel Shamy, Franco Momoli, Rebecca Thornhill, Ronda Lun, Carlos Torres\",\"elocationId\":null,\"journalName\":\"Stroke and Vascular Neurology\",\"publicationYear\":\"2023\",\"volume\":\"8\"}\n24:{\"title\":\"Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort\",\"articleUrl\":\"https://svn.bmj.com/content/8/3/194\"}\n26:[[\"Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada\",1],[\"Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada\",2],[\"School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada\",3],[\"Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada\",4],[\"Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada\",5],[\"Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada\",6],[\"Medicine, Queen's University, Kingston, Ontario, Canada\",7]]\n2a:T40b,The aetiology of FFT was determined based on imaging appearance and medical record review as: (1) carotid atherosclerotic disease if there was residual plaque identified on follow-up CTA imaging directly adjacent to, or in contact with the filling defect after FFT resolution, and with no other potential cause identified; (2) carotid dissection; (3) cardioembolism if no adjacent plaque or dissection was identified after resolution and cardiac testing revealed atrial fibrillation or any other known cardiac source; (4) possible "])</script><script>self.__next_f.push([1,"carotid atherosclerosis or cardioembolism where both adjacent plaque and a known cardiac source were discovered or (5) embolic stroke of uncertain source (ESUS) where no ipsilateral plaque was identified and aetiological testing was unrevealing. Patients with an adjacent carotid plaque were further subclassified as having ≥50% or \u003c50% stenosis. All imaging assessments for aetiology were by consensus of two neuroradiologists. Aetiological workup followed the Canadian Best Practice Recommendations2d:T71e,\u003chtml\u003e\u003chead\u003e\u003c/head\u003e\u003cbody\u003e\u003cdiv class=\"section fn-group\" id=\"fn-group-1\"\u003e\u003cul\u003e\u003cli class=\"fn-other\" id=\"fn-1\"\u003e\u003cp id=\"p-24\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eContributors:\u003c/span\u003e DD and CL conceived the study. DD, CL, FM and RT designed the methodology. DD, CL, CT, AB, DB, GS, MS and BM executed the study and enrolled patients. CL, CT, PP-P, RL and RT reviewed imaging. PD, DD, RL, PP-P, RT and FM performed analyses. All authors contributed to writing. DD, CT and CL provided supervision. DD is the guarantor of the overall content.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-2\"\u003e\u003cp id=\"p-25\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eFunding:\u003c/span\u003e This study was funded by uOttawa Department of Medicine.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-conflict\" id=\"fn-3\"\u003e\u003cp id=\"p-26\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eCompeting interests:\u003c/span\u003e None declared.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-4\"\u003e\u003cp id=\"p-27\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eProvenance and peer review:\u003c/span\u003e Not commissioned; externally peer reviewed.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-5\"\u003e\u003cp id=\"p-28\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eSupplemental material:\u003c/span\u003e 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. 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Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.\"]}]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-2\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-3\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Methods\"}],\" We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or \u003c50% stenosis.\"]}]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-3\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-4\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Results\"}],\" We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.\"]}]}],[\"$\",\"div\",\"4\",{\"id\":\"sec-4\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-5\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Conclusions\"}],\" The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.\"]}]}]],[\"$\",\"$L28\",null,{}]]}],false]}],[\"$\",\"$20\",\"3\",{}],[\"$\",\"$20\",\"4\",{\"children\":[[\"$\",\"div\",null,{\"className\":\"section notes text-bmj-silver-800 border-bmj-silver-100 rounded-lg [\u0026_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [\u0026_p]:my-[8px] [\u0026_li]:m-0 [\u0026_li]:p-0 [\u0026_h3]:mb-0 [\u0026_h3]:mt-[10px] [\u0026_h3]:text-[1.25rem] [\u0026_h3]:font-normal\",\"children\":[\"$\",\"div\",null,{\"data-testid\":\"article-notes-content\",\"className\":\"article-notes-content\",\"children\":[\"$\",\"div\",null,{\"className\":\"\",\"id\":\"boxed-text-1\",\"children\":[[\"$\",\"h3\",\"0\",{\"data-testid\":\"article-notes-subheader\",\"children\":\"What is already known on this topic\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-1\",\"children\":[[\"$\",\"li\",\"0\",{\"id\":\"list-item-1\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-6\",\"children\":\"Carotid free-floating thrombi (FFT) are high risk for stroke recurrence.\"}]}],[\"$\",\"li\",\"1\",{\"id\":\"list-item-2\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-7\",\"children\":\"Carotid FFT are associated with local plaque rupture.\"}]}]]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-5\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"What this study adds\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-2\",\"children\":[[\"$\",\"li\",\"0\",{\"id\":\"list-item-3\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-8\",\"children\":\"Up to 40% of carotid FFT have associated stenosis requiring revascularisation.\"}]}],[\"$\",\"li\",\"1\",{\"id\":\"list-item-4\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-9\",\"children\":\"Up to 20% of carotid FFT have a non-atherosclerotic aetiology.\"}]}]]}]]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-6\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"How this study might affect research, practice or policy\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-3\",\"children\":[\"$\",\"li\",null,{\"id\":\"list-item-5\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-10\",\"children\":\"Carotid FFT require investigation for non-atherosclerotic aetiologies.\"}]}]}]]}]]}]}]}],[\"$\",\"$L29\",null,{\"testId\":\"middle-ad-slot-1\",\"slotId\":\"div-gpt-ad-1686906823508-1\"}]]}],[\"$\",\"$20\",\"5\",{\"children\":[[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls pb-[24px]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-7\",{\"id\":\"sec-7\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Introduction\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-11\",\"children\":[\"Carotid free-floating thrombi (FFT) are present in 1.6%–3.7% of patients presenting with acute transient ischaemic attack (TIA)/stroke.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-1-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" While relatively uncommon, FFT are high-risk lesions with an approximately 11% risk of stroke or death within 30 days of diagnosis.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-2-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-2\",\"children\":\"2\"}],\" Immediate management typically consists of antithrombotic medications,\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-1-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" although there is no consensus on the optimal therapeutic agent or duration of therapy.\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-12\",\"children\":[\"The majority of FFT are believed to originate from local atherosclerotic plaque rupture. Moreover, many are associated with a significant degree of underlying carotid stenosis.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-1-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" However, FFT are also reported in association with dissections, coagulopathy and malignancy, and can be associated with cardioembolism.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-1-4\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1 3 4\"}],\" The relative proportion of atherosclerotic versus non-atherosclerotic causes of FFT is unknown.\"]}],[\"$\",\"p\",\"3\",{\"id\":\"p-13\",\"children\":\"Our primary objective was to explore and classify the underlying aetiology of carotid thrombi in a well-characterised consecutive, prospective, multicentre cohort of patients presenting with TIA/stroke symptoms and confirmed ipsilateral FFT. Our secondary objective was to characterise the degree of underlying stenosis when the FFT was associated with local atherosclerotic plaque.\"}]]}],[\"$\",\"$L28\",null,{}]]}],false]}],[\"$\",\"$20\",\"6\",{\"children\":[[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls pb-[24px]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-8\",{\"id\":\"sec-8\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Methods\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-14\",\"children\":[\"We prospectively enrolled consecutive patients presenting to the emergency departments of the Ottawa Hospital (Ottawa, Canada), Calgary Foothills Hospital (Calgary, Canada) and St. Michael’s Hospital (Toronto, Canada) with a diagnosis of acute TIA/stroke within 24 hours of symptom onset. Details of the study (ClinicalTrials.gov \",[\"$\",\"a\",\"1\",{\"href\":\"https://clinicaltrials.gov/study/NCT02405845\",\"target\":\"_blank\",\"rel\":\"noreferrer\",\"children\":\"NCT02405845\"}],\") are published elsewhere.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-5-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" Patients were enrolled if the CT angiography (CTA) at presentation revealed an ipsilateral internal carotid artery (ICA) lesion suspected to represent an FFT, based on the appearance of an intraluminal filling defect. Diagnosis of FFT was confirmed by either the resolution or decrease in size of the filling defect seen on serial CTA, based on consensus review by two neuroradiologists, or intraoperative pathology during carotid endarterectomy. Antithrombotic therapy and the timing of repeat clinical CTAs were at the discretion of the treating physician. In patients where no resolution or decrease in size of the filling defect was observed on CTAs in the first month, a CTA was performed at 5 weeks following symptom onset, as per study protocol; if the lesion was unchanged on this repeat CTA, it was deemed not to be FFT. The threshold of 5 weeks was chosen a priori based on prior work demonstrating that all confirmed FFT decreased in size within 3 weeks of symptom onset.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-6-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-6\",\"children\":\"6\"}],\"\\n\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-15\",\"children\":[\"$2a\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-7-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-7\",\"children\":\"7\"}],\" and included cardiac transthoracic echocardiography and ambulatory rhythm monitoring for 14 days to assess for atrial fibrillation. After completing the initial prospective study, a medical record review was conducted for any additional aetiological workup. Source data will be available on reasonable request to the lead investigators.\"]}]]}],[\"$\",\"$L28\",null,{}]]}],false]}],[\"$\",\"$20\",\"7\",{\"children\":[[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls pb-[24px]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-9\",{\"id\":\"sec-9\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Results\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-16\",\"children\":[\"We enrolled 100 patients with suspected FFT: 1 subject withdrew consent and 4 were excluded from the study due to protocol deviations (3 patients did not have a repeat CTA to confirm FFT, and 1 patient was erroneously enrolled with a vertebral artery thrombus). Detailed information on the full study cohort is published elsewhere.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-5-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" Eighty-three patients had confirmed FFT on follow-up imaging (median confirmatory follow-up scan at 4 days) and were included in our analysis (\",[\"$\",\"a\",\"3\",{\"id\":\"xref-table-wrap-1-1\",\"className\":\"xref-table\",\"href\":\"#T1\",\"children\":\"table 1\"}],\"). Two patients experienced recurrent events: one TIA and one stroke requiring thrombectomy.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-5-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\"\\n\"]}],[\"$\",\"$L2b\",\"2\",{\"title\":\"Table 1\",\"description\":\"Baseline characteristics of patients confirmed to have a carotid free-floating thrombus\",\"children\":[[\"$\",\"table\",\"0\",{\"frame\":\"hsides\",\"rules\":\"groups\",\"id\":\"table-1\",\"children\":[[\"$\",\"thead\",\"0\",{\"id\":\"thead-1\",\"children\":[\"$\",\"tr\",null,{\"id\":\"tr-1\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"bottom\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-1\",\"className\":\"table-left table-vbottom\",\"children\":null}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"bottom\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-2\",\"className\":\"table-left table-vbottom\",\"children\":\"N=83\"}]]}]}],[\"$\",\"tbody\",\"1\",{\"id\":\"tbody-1\",\"children\":[[\"$\",\"tr\",\"0\",{\"id\":\"tr-2\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-3\",\"className\":\"table-left table-vtop\",\"children\":\"Baseline characteristics\"}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-4\",\"className\":\"table-left table-vtop\",\"children\":null}]]}],[\"$\",\"tr\",\"1\",{\"id\":\"tr-3\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-5\",\"className\":\"table-left table-vtop\",\"children\":[\" Age at presentation\",[\"$\",\"br\",\"1\",{\"children\":null}],\" (mean±SD)\"]}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-6\",\"className\":\"table-left table-vtop\",\"children\":\"67.2±14.0\"}]]}],[\"$\",\"tr\",\"2\",{\"id\":\"tr-4\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-7\",\"className\":\"table-left table-vtop\",\"children\":\" Female sex (n,%)\"}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-8\",\"className\":\"table-left table-vtop\",\"children\":\"30 (36.1)\"}]]}],[\"$\",\"tr\",\"3\",{\"id\":\"tr-5\",\"children\":[\"$\",\"td\",null,{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"2\",\"id\":\"td-9\",\"className\":\"table-left table-vtop\",\"children\":\"Medical history\"}]}],[\"$\",\"tr\",\"4\",{\"id\":\"tr-6\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-10\",\"className\":\"table-left table-vtop\",\"children\":\" Coronary artery disease 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(3.6)\"}]]}]]}]]}],[\"$\",\"div\",\"1\",{\"className\":\"table-foot\",\"children\":null}]]}],[\"$\",\"p\",\"3\",{\"id\":\"p-18\",\"children\":[\"Aetiological assessment revealed that 66/83 (79.5%) patients had an underlying adjacent atherosclerotic plaque. Another 10/83 (12%) had both atrial fibrillation and adjacent atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 3/83 (3.6%) were classified as ESUS and no patient had atrial fibrillation in the absence of adjacent plaque. Of the 76 patients with adjacent atherosclerotic disease (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis (details in \",[\"$\",\"a\",\"1\",{\"id\":\"xref-supplementary-material-1-1\",\"className\":\"xref-supplementary-material\",\"href\":\"#DC1\",\"children\":\"online supplemental table 1\"}],\"). Of the four patients classified as ESUS, one was a 25-year-old patient with patent foramen ovale, and two were suspected of having hypercoagulability (one due to lung carcinoma and one related to ulcerative colitis).\"]}],[\"$\",\"$20\",\"4\",{}]]}],[\"$\",\"$L28\",null,{}]]}],false]}],[\"$\",\"$20\",\"8\",{\"children\":[[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls pb-[24px]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-10\",{\"id\":\"sec-10\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Discussion\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-20\",\"children\":[\"These results show that atherosclerotic plaque rupture may be the likely aetiology in at least four out of every five patients presenting with FFT and TIA/stroke. This number could be higher if it is assumed that FFT is due to plaque rupture in patients with a coexisting aetiology, that is, with both atrial fibrillation and local atherosclerotic plaque. Moreover, over half of these patients had underlying carotid stenoses of ≥50% warranting urgent revascularisation, which is comparable to a recent single-centre cohort study.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-1-5\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" These findings highlight an important knowledge gap in FFT management in the context of symptomatic carotid stenosis: should such patients be offered early revascularisation, or should there be a period of antithrombotic therapy to reduce thrombus burden prior to either endarterectomy or carotid artery stenting? Immediate treatment with the combination of anticoagulation and antiplatelet therapy is associated with partial or complete resolution of FFT in 75%–86.5% of patients within a median time of 4–6 days.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-1-6\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1 5\"}],\" This must be weighed against the early recurrent stroke risk associated with delaying revascularisation for symptomatic carotid stenosis, which can be as high as 7.9% in the first week.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-8-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-8\",\"children\":\"8\"}],\" These two approaches may warrant further study in a comparative randomised trial.\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-21\",\"children\":\"Between 8% and 20% of patients presenting with FFT have a non-atherosclerotic aetiology in this study (with the higher number of this range based on the assumption that those with both atrial fibrillation and atherosclerosis were the result of cardio-embolism). Approximately 5% of these FFTs were secondary to carotid dissections in the acute setting, but the remaining FFTs required additional investigations to identify other aetiologies (arrhythmias, malignancies and other causes of hypercoagulability). This suggests that up to 15% of FFTs may result from a process distant from the carotid artery. Furthermore, approximately 1 of every 25 patients met the criteria for ESUS, highlighting the need for vigilance and additional investigations in the setting of FFT.\"}],[\"$\",\"p\",\"3\",{\"id\":\"p-22\",\"children\":\"The strengths of our study include the study protocol-specified prospective consecutive enrolment, the validated FFT diagnostic criteria and the multicentre recruitment. But our study has important limitations. While atrial fibrillation was either known or discovered in 12% of patients, it is possible that its prevalence as an aetiology of FFT was underestimated. Conversely, local plaque rupture could also be underestimated as atheromatous changes below the detection threshold of CTA or atheroma proximal to the ICA could also give rise to FFT. For these reasons, we believe the estimates for FFT aetiology are likely to range from 80% to 92% for local plaque rupture and up to 16% for cardioembolism. Finally, our study did not collect information around the management of underlying carotid stenosis, therefore, we were not able to assess how the presence of FFT affected revascularisation decisions.\"}],[\"$\",\"p\",\"4\",{\"id\":\"p-23\",\"children\":\"In summary, the majority of symptomatic carotid artery FFT are caused by local atherosclerotic plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, FFT are also caused by non-atherosclerotic mechanisms warranting additional investigations for cardioembolism, hypercoagulability and malignancy. 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