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    Risk of Paradoxical Embolism (RoPE) Score

    Identifies stroke-related PFO in patients with cryptogenic stroke.
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    INSTRUCTIONS

    Use in patients with cryptogenic stroke found to have PFO and no other compelling cause for stroke.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with cryptogenic embolic ischemic strokes found to have PFO.

    • 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 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.
    • 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.
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    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Although the RoPE score was not designed to predict treatment effect, other studies have looked at predictors of recurrence in PFO-related stroke (Thaler 2014), which may help in deciding which patients may be appropriate for PFO closure.  
    • Consult cardiology for patients in whom suspicion for PFO-attributable stroke is high based on the RoPE score.

    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).

    Content Contributors
    • Emiliya Melkumova, MD
    About the Creator
    Dr. David Thaler
    Are you Dr. David Thaler?
    Content Contributors
    • Emiliya Melkumova, MD