The simultaneous occurrence of SCAD and luminal thrombus is rare with prevalence of under 5 % in autopsy studies [ ]. However, it is important to note that SCAD can lead to flow reduction and subsequent thrombus formation, which may not always be apparent on angiography. Given that most SCAD cases are treated conservatively without intravascular imaging, the true incidence of SCAD-associated thrombosis may be more common than thought. This case not only demonstrates this potentially underrecognized combination but also highlights the complex decision-making process in managing such presentations.