Physician Approaches to the Initial Management of an Intraluminal Thrombus in Recently Symptomatic Carotid Artery Stenosis: Results from the Hot Carotid Study
Davis MacLean 1, Benjamin Beland1, Gordon Jewett1, Luca Bartolini2, David JT Campbell1, Malavika Varma1, Ravinder Singh3, Abdulaziz Al-Sultan1, John Wong1, Bijoy Menon1, Aravind Ganesh4
1University of Calgary, 2Hasbro Children's Hospital, 3Northern Ontario School of Medicine, 4Department of Clinical Neurosciences, University of Calgary
Objective:

To use mixed methods to explore the practices of international experts when managing patients with an intraluminal carotid artery thrombus in the context of recently symptomatic carotid artery stenosis.

Background:

Intraluminal thrombi (ILT) are thought to be at high short-term risk of recurrent ischemic events without revascularization and high risk of peri-operative stroke when early revascularization is attempted. Due to the lack of high-quality evidence, ILT management approaches rely on individual or institutional preferences, but the current state of practice is unclear.

Design/Methods:

This mixed methods study analyzed themes from semi-structured interviews with 22 stroke physicians from 16 centers in 6 world regions, paired with a worldwide case-based survey of 628 stroke physicians conducted through the “Practice Current” section of Neurology: Clinical Practice.

Results:

In the thematic analysis of the interviews and quantitative analysis of the survey, participants generally favoured using anticoagulation with or without one or more antiplatelet agents at least short-term in patients with ILT (463/628, 74%). Despite a preference for anticoagulation, a theme of uncertainty regarding optimal antithrombotic management was present in the thematic analysis. Multivariable regression analysis of the survey data also showed significant regional variability regarding antithrombotic choices in treating ILT, with the USA and Canada favouring anticoagulation compared to other surveyed regions. Additional themes identified included a preference for re-imaging patients in 3-5 days after initiating treatment to look for complete or partial clot resolution, at which point most experts would then be comfortable proceeding with revascularization if indicated, though significant uncertainty regarding the optimal timing of revascularization was noted in the analysis.

Conclusions:

These results highlight current practice patterns in patients with ILT and show that while there appears to some preference for using anticoagulant agents and reimaging patients in 3-5 days, there is still considerable equipoise regarding the most appropriate management of patients with ILT.

10.1212/WNL.0000000000202755