Management of carotid artery web: a nationwide survey of vascular neurologists versus neurointerventionalists

BACKGROUND: Carotid artery web (CW) is an under-recognized cause of cryptogenic stroke, with variability in practice and controversy regarding its optimal management. Due to the lack of society guidelines, it is unclear how neurointerventional radiologists (NIRs) and vascular neurologists approach this condition. Therefore, we conducted a survey to understand practice patterns for the management of CW. METHODS: A 10-question survey, including demographic data and clinical vignettes, was developed using REDCap (Research Electronic Data Capture) and sent to board-certified vascular neurologists and NIRs. Responses were categorized into binary outcomes (medical therapy vs carotid revascularization). Statistical analyses, including Chi-square, Fisher's exact, and Kruskal-Wallis, were used for group comparisons. RESULTS: Of 1640 participants, 247 completed the survey, with 77% being vascular neurologists and 23% neurointerventionalists. Participants identified cryptogenic stroke (80.1%) and recurrent stroke (74.4%) as key factors considering CW as the underlying stroke etiology. For a cryptogenic ischemic stroke, neurointerventionalists were more likely than neurologists to favor carotid revascularization (52% vs 37%, p=0.035). In patients with ischemic stroke and competing mechanisms such as atrial fibrillation, nearly half of neurointerventionalists, but only one-third of neurologists, recommended revascularization for secondary prevention (48% vs 31%, p=0.021). NIRs, when compared with neurologists, had a strong preference for carotid artery stenting over carotid endarterectomy (86% vs 35%, p=0.002). CONCLUSIONS: There is clinical equipoise regarding the management of CW and ischemic stroke. Randomized clinical trials are needed to minimize variability in treatment approaches.