Objective:

To compare the effectiveness and safety of anticoagulation versus antiplatelet therapy in the management of ICT/CFFT associated with AIS or TIA

Background:

Intraluminal carotid thrombus (ICT) or carotid free-floating thrombus (CFFT) is a rare but high-risk cause of acute ischemic stroke (AIS) and transient ischemic attack (TIA). The optimal medical therapy remains uncertain, with both anticoagulation and antiplatelet agents commonly used in clinical practice.

Design/Methods:

A systematic review and meta-analysis were performed according to PRISMA guidelines. Five retrospective cohort studies published between 2013 and 2024, including 214 patients, met inclusion criteria. Data on thrombus resolution, functional recovery (modified Rankin Scale ≤ 2), and hemorrhagic events were extracted and pooled using random-effects models.

Results:

Among the included studies, 164 patients received anticoagulation and 50 received antiplatelet therapy. Pooled thrombus resolution with anticoagulation was 98% (95% CI 0.00–1.00), and 91% achieved good functional outcomes (95% CI 0.82–0.96). Comparative analyses showed a nonsignificant trend favoring anticoagulation for thrombus resolution (OR 1.89, 95% CI 0.79–4.55) but with a higher, though not statistically significant, risk of hemorrhage (OR 1.99, 95% CI 0.62–6.42).

Conclusions:

Anticoagulation demonstrates high rates of thrombus resolution and favorable functional recovery in patients with ICT/CFFT but may carry a greater bleeding risk compared with antiplatelet therapy. Current evidence does not establish clear superiority of one strategy over the other. Prospective, multicenter studies are warranted to define optimal medical management and identify patient-specific factors guiding therapy selection.