We experienced two ischemic stroke patients with floating thrombus (FT) coupled with a high-grade stenosis of the internal carotid artery (ICA). They demonstrated different clinical outcomes after conventional treatment. An 83-year-old woman exhibited drowsiness, motor aphasia, and right-sided hemiparesis. Magmetic resonance (MR) images on admission displayed multiple infarctions in the territory of the left deep border zone, and MR angiograms revealed poor visualization of the left ICA. Emergency cerebral angiograms disclosed a high-grade ostial stenosis of the left ICA with FT. Brain perfusion-weighted MR images (PWI) showed no laterality. The patients was treated with intravenous heparin and oral antiplatelets, and her neuro-logical symptoms improved. Carotid ultrasonography revealed no FT at 16 days later, and the patient underwent carotid stenting. Her modified Rankin Scale was 1 at 3 months after her ischemic stroke onset. An 82-year-old man exhibited drowsiness, total aphasia, conjugate deviation and right-sided hemiparesis. MR images on admission displayed infarction in the territory of the left corona radiata, and MR angiograms revealed poor visualization of the left ICA. Emergency cerebral angiograms disclosed a high-grade ostial stenosis of the left ICA with FT. Brain PWI showed no laterality. Although the patient was treated with intravenous heparin and oral antiplatelets, his neurological symptoms deteriorated, FT disappeared at 27 days later, and the patient underwent carotid stenting. However, his neurological symptoms were no longer improved after the procedure. His modified Rankin Scale remained 5 at 3 months after his ischemic stroke onset. When neurologi-cal symptoms begin to deteriorate after starting conventional treatment, carotid artery reconstruction may be a treatment of choice. The 3-month clinical outcome after intravenous heparin and oral antiplatelets varies in patients with FT coupled with a high-grade stenosis of the ICA.
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