Carotid free-floating thrombus (CFFT) is a rare but high-risk condition for embolic events, often leading to acute ischemic stroke or transient ischemic attack. The pathogenesis of CFFT remains incompletely understood, with most cases related to rupture of atherosclerotic plaques. Imaging plays a central role in the diagnosis of CFFT, and noninvasive imaging techniques have become the main diagnostic tools in recent years. Although understanding of CFFT has deepened, the rarity of cases and lack of large-scale studies mean that standardized treatment guidelines are still unavailable. Current treatment strategies mainly include anticoagulation, antiplatelet therapy, and surgical or endovascular intervention. Despite the increasing number of recent small-scale observational studies on CFFT, the optimal management strategy remains controversial. This review summarizes recent evidence on the epidemiology, pathogenesis, imaging diagnosis, and current treatment strategies of CFFT, aiming to enhance early recognition and standardized management in clinical practice and to provide insights for future high-quality prospective studies.