An ascending aortic arch thrombus (ACT) is a rare finding in an anatomically normal aorta. It can be seen with aortic dissection or aneurysm. Complications of large thrombus like stroke or systemic emboli are less likely when found in normal aorta. Even with the low risk embolic events, it is even less likely if patients are on therapeutic anticoagulation. Here we discuss this rare case in detail. 49 y/o with PMHx of HTN, HLD, COVID19, DVT s/p thrombectomy, noncompliant with warfarin, ICH from fall presents with left-sided weakness and blurry vision. MRI head showed scattered acute infarction along right PCA with occlusion, an old right ACA infarct, and left cerebellar hemorrhage. The patient was not a candidate for intervention or IV alteplase. TTE showed normal LVEF, a large mobile ACT. TEE showed an 8.7 cm pedunculated heterogeneous ACT, traversing into the aortic arch. No evidence of AFib activity on telemetry. CTS and hematology were consulted. The patient was negative for inherited hypercoagulable disease or malignancy. The ACT was attributed to the history of COVID19, and the patient was medically managed on coumadin. Shortly after, they presented to ED with recurrent stroke-like symptoms. CTS resected ACT and did hemiarch repair. The mass was sent for pathology, which confirmed an organized thrombus. The patient was discharged on Eliquis given the development of stroke on warfarin. There is limited evidence on optimal management of an ACT. Treatments include medical management with anticoagulation or in combination with surgical interventions. Anticoagulation alone has a risk of clot dissolution and deadly embolic events. Factors favoring the surgery include patient history, size, location, mobility of thrombus, or an inability to distinguish ACT from mass on imaging. A combination is recommended postoperatively.