Thrombectomy for ICA Thrombus in Ischemic Stroke with Malignancy Shows Positive Language Outcomes

Introduction Ischemic stroke in the setting of advanced malignancy poses unique challenges due to competing risks of hypercoagulability and hemorrhage. We present a case of tandem occlusion caused by a free‐floating internal carotid artery (ICA) thrombus in a patient with metastatic adenocarcinoma, highlighting individualized decision‐making in reperfusion therapy. Materials/Methods A 59‐year‐old Mandarin‐speaking woman with stage IV lung adenocarcinoma, malignant pleural effusions (with PleurX catheter), malignant ascites, recent chemotherapy (amivantamab, pemetrexed, carboplatin) and left parietal AVM presented with sudden‐onset aphasia (last known well 3 hours). On arrival, she was awake but non‐verbal, not following commands despite interpreter assistance, with subtle left gaze preference and evolving right‐sided weakness (NIHSS 16). Non‐contrast CT showed subtle left MCA ischemic changes. CTA revealed a proximal free‐floating left ICA thrombus with tandem left M2 occlusion. Given prohibitive hemorrhagic risk from malignant effusions, ascites and AVM, IV thrombolysis was withheld. She underwent urgent mechanical thrombectomy with neuro‐ICU admission. Results Reperfusion was successfully achieved, with significant improvement in language function toward her baseline. The combination of proximal free‐floating ICA thrombus and distal MCA occlusion illustrated malignancy‐associated tandem pathology within a hypercoagulable milieu. Conclusion This case underscores several key points: free‐floating ICA thrombus is a rare but important malignancy‐associated cause of tandem occlusion; cancer‐related coagulopathy can present with atypical clot morphology and recurrence risk; and reperfusion strategies must balance guideline‐based therapies against individualized bleeding risks. Mechanical thrombectomy provided safe and effective treatment where IV thrombolysis was contraindicated. Recognition of stroke in oncology patients may be delayed by language barriers, treatment effects, and overlapping symptoms. This report contributes to the limited literature on thrombectomy outcomes in cancer patients with concurrent extracranial bleeding risks and cerebrovascular anomalies.