Risk of Paradoxical Embolism (RoPE) Score
Why Use
Prevalence of PFO in the general population is high (~25%). In patients presenting with cryptogenic stroke who are found to have PFO, it is difficult to assess whether the PFO caused their stroke or if the PFO is an incidental finding. The RoPE score helps risk stratify the causal relation of PFO to stroke.
When to Use
Patients with cryptogenic embolic ischemic strokes found to have PFO.
Formula
Pearls / Pitfalls
The Risk of Paradoxical Embolism (RoPE) Score was developed to identify patients with cryptogenic stroke and PFO in whom PFO was likely to be the cause of their stroke. A high RoPE score in a patient with cryptogenic embolic ischemic stroke and PFO, and without another convincing etiology, highly suggests causality of stroke to be PFO-related, but does not prove it. PFO may act as a conduit for a paradoxical embolus that originated in the venous system, or may act as a nidus for clot formation. Should NOT be used to decide which stroke patients should undergo echocardiography. Should NOT be used to decide which cryptogenic stroke patients with PFO should undergo PFO closure.
Management
Consider referral for PFO closure in appropriately-selected patients with higher RoPE scores.
Critical Actions
Do not forget to rule out other, or contributing, causes for stroke (e.g. hypercoagulable state).
Advice
Decisions regarding which patients should be selected for PFO closure should be carefully weighed by the treating neurologist and cardiologist. The RoPE Score provides important information about the probable biological mechanism, which is key for making mechanism-specific therapeutic decisions, such as whether to close a PFO or treat with medication alone. Additional studies are necessary to better motivate firmer decision rules for patient selection. Consult cardiology for patients in whom suspicion for PFO-attributable stroke is high based on the RoPE score.
More Information
Score interpretation: RoPE score PFO-attributable fraction (95% CI) Estimated stroke/TIA recurrence at 2 years 0-3 0% (0–4) 20% (12–28) 4 38% (25–48) 12% (6–18) 5 34% (21–45) 7% (3–11) 6 62% (54–68) 8% (4–12) 7 72% (66–76) 6% (2–10) 8 84% (79–87) 6% (2–10) 9-10 88% (83–91) 2% (0–4)