How do you acutely manage a free-floating thrombus in a major artery in a patient with a stroke as a result of it?  

There is no clear guidance from trials. My own practice has been to anticoagulate for 72 hours, then repeat the CTA. If the thrombus is no longer visible, I switch to dual anti-platelet Rx; if still there switch to DOAC for 30 days and reimage.

If there is significant brain in that territory left to harm, I would heparinize the person and transition to anticoag for 6 weeks unless another indication for longer term anti-thrombotic therapy is known. 

Very interesting question. Although there is no randomized trial to evaluate for the best management but there are 2 important questions I ask myself before considering treatment: Where is this free-floating thrombus? Cervical carotid which likely means there is a ruptured plaque and thrombus ...

In the absence of significant data, I'm sure practice patterns will vary widely. I think we all worry about a high risk of recurrent embolization in these patients. Where I've practiced, we would typically heparinize, re-evaluate for early improvement (within days to a week), and consider continued ...