COVID-associated free-floating thrombus presenting with acute stroke

Introduction: Recent trials have identified an association between COVID-19 and ischemic stroke, particularly through the formation of free-floating thrombus (FFT). This report highlights cases of acute ischemic stroke caused by FFT in COVID-19 patients, usually asymptomatic. An FFT is a thrombus attached to an arterial wall but with a free-floating distal end, leading to embolic events and high mortality. It can be present as recurrent transient ischemic attacks, characterized by episodic neurological ischemia. Case Report: Case 1 involves an elderly diabetic woman, presenting with sudden bilateral vision loss, unsteady gait, and drowsiness. Neuroimaging revealed a left occipital infarct and FFT in the right vertebral artery. Case 2 involves a woman, with COVID-19 infection, who presented with right-sided hemiparesis and slurred speech. Imaging confirmed FFT in the left internal carotid artery and a left parietal infarct. Both patients were treated with thrombolysis (tenecteplase), anticoagulation, and antiplatelet therapy. Follow-up imaging at two weeks showed complete resolution, and both patients showed neurological improvement with rehabilitation. Conclusion: Both the cases highlight the importance of awareness of FFT as a potential complication in post-COVID-19 patients, especially those who were present with unexplained neurological deficits. Early diagnosis and prompt treatment, including anticoagulation and thrombolysis, leads to favorable outcome.