To examine the decision-making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for patients with acutely symptomatic carotid stenosis (“hot carotid”).

Evidence informing the choice between carotid endarterectomy(CEA) and stenting(CAS) for acutely symptomatic carotid stenosis dated and does not factor in contemporary therapies/techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis.

Using a qualitative descriptive methodology, we conducted semi-structured interviews with purposive sampling of 22 stroke physicians from 16 centers representing six world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons.

Qualitative analysis revealed several themes regarding clinical decision-making for hot carotids. Whereas CT angiography(CTA) was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. CEA was generally favored over CAS, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization and the role of intervention with borderline stenosis or intraluminal thrombus.

This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CTA imaging and CEA over CAS, but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk-stratification with imaging features other than just degree of stenosis.