Presence of carotid mural thrombi without underlying mural wall changes is relatively rare3.In our case we could demonstrate free floating thrombus on one side and eccentric thrombus on other side. Most floating thrombi are associated with atheromatous plaques, cardiogenic emboli, arterial dissections and systemic diseases related to coagulopathic states. Most patients presented with transient neurologic symptoms, were younger than typically seen with atherosclerotic carotid disease, and were predominantly male. Our index case is a female  and we could find the possible cause due to low protein C levels. Almost all of the patients reported in the literature were symptomatic. The natural history of either symptomatic or asymptomatic patients is not known, although one would expect it to be adverse in the former. The diagnostic methods used to reveal FFT-common carotid artery are Doppler ultrasonography (DU), digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomographic angiography (CTA) scan. Angiography was used heavily in the diagnostic phase of carotid thrombi and free floating thrombi. Despite one case report where a stroke was precipitated during a duplex ultrasound examination of a FFT, DU imaging remains the safest and least invasive study. In addition DU imaging has the advantage of repeating at frequent intervals for follow up, without any further risks of radiation or contrast administration4.Different kinds of treatment have been described, including medical management  alone, medical management with delayed surgery, urgent carotid thromboendarterectomy, or endovascular repair of the lesion with cerebral protection5.Clinical outcomes of these treatment modalities are approximately same. Our decision to treat this patient medically in the acute phase was due primarily to stable neurologic condition upon presentation.  Important radiographic predictors of clinical deterioration were also absent, specifically, a lack of flow limitation due to the thrombus in the cervical region and the  absence of proximal occlusion in the intracranial circulation.Bilateral carotid thrombi are extremely rare. Early diagnosis and treatment of carotid artery  thrombosis is important to help reduce the morbidity and mortality associated with stroke.  This report highlights the role of doppler imaging in diagnosis and follow up of these  lesions. Medical therapy may be effective  in selected patients with FFT who are clinically  stable and have low risk radiographic profile in regards to early recurrence of symptoms.

ACUTE STROKE WITH BILATERAL CAROTID THROMBI - A MAJOR CHALLENGE FOR STROKE NEUROLOGIST