Risk of Paradoxical Embolism (RoPE) Score
Stratifies cryptogenic stroke (CS) patients with patent foramen ovale (PFO) by their likelihood of PFO-related stroke.
Refer to the text below the calculator for more information on the RoPE score and the original study.
Whilst the prevalence of patent foramen ovale (PFO) is general population is high (almost 1 in 4 people), the causal relation between cryptogenic stroke and PFO is difficult to establish so the RoPE score was proposed to address this exact issue.
So the RoPE score is aimed at identifying patients presenting with cryptogenic stroke where the most likely cause of the stroke is PFO.
However please note that whilst the relationship of causality may be very strong in cases of cryptogenic embolic ischemic stroke and PFO, where no other etiology is present, it still cannot be proven with 100% accuracy and other stroke contributing causes may still require investigation.
| 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) |
The RoPE score is a risk strafication tool and should not be used in deciding which patients are further echocardiographed not which patients should undergo PFO closure.
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The RoPE score explained
Cryptogenic stroke (CS) is the type of cerebral ischemia of obscure or unknown origin occurring in 1 out of 3 stroke cases. When the cause remains unknown it is either because the event is transitory or reversible, investigations are limited for some reason or the cause does not become apparent regardless of investigations.
Whilst the prevalence of patent foramen ovale (PFO) is general population is high (almost 1 in 4 people), the causal relation between cryptogenic stroke and PFO is difficult to establish so the RoPE score was proposed to address this exact issue.
So the RoPE score is aimed at identifying patients presenting with cryptogenic stroke where the most likely cause of the stroke is PFO.
However please note that whilst the relationship of causality may be very strong in cases of cryptogenic embolic ischemic stroke and PFO, where no other etiology is present, it still cannot be proven with 100% accuracy and other stroke contributing causes may still require investigation.
The Risk of Paradoxical Embolism score consists in 6 factors, found to be associated with PFO incidence in CS patients:
| ROPE score item | Points |
| No history of hypertension | 1 |
| No history of diabetes | 1 |
| No history of stroke or TIA | 1 |
| Nonsmoker | 1 |
| Cortical infarct on imaging | 1 |
| Age in years | - |
| 18-29 | 5 |
| 30-39 | 4 |
| 40-49 | 3 |
| 50-59 | 2 |
| 60-69 | 1 |
| ≥70 | 0 |
The 10-point RoPE score is calculated from these items so that the youngest patients with superficial strokes and without vascular risk factors have the highest score.
| 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) |
The RoPE score is a risk strafication tool and should not be used in deciding which patients are further echocardiographed not which patients should undergo PFO closure.
About the original study
The RoPE score was published by Kent et al. following a study on the data of 3,023 patients from 12 databases. A predictive model for statistical relatedness of PFO to stroke etiology was developed for use in patients with cryptogenic stroke and a simple index to stratify patients was derived.
The study also estimated the the stratum-specific PFO-attributable fraction and stratum-specific stroke/TIA recurrence rates.
PFO prevalence increased from 23% (95% confidence interval [CI]: 19%-26%) for scores of 0 to 3 points to 73% (95% CI: 66%-79%) for scores of 9 or 10 points, corresponding to attributable fraction estimates of approximately 0% to 90%.
Patients in strata more likely to have stroke-related PFOs (scores of 9 or 10) have lower stroke recurrence risk.
References
Original reference
Kent DM, Ruthazer R, Weimar C, Mas JL, Serena J, Homma S, Di Angelantonio E, Di Tullio MR, Lutz JS, Elkind MS, Griffith J, Jaigobin C, Mattle HP, Michel P, Mono ML, Nedeltchev K, Papetti F, Thaler DE. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81(7):619-25.
Validation
Prefasi D, Martínez-Sánchez P, Fuentes B, Díez-Tejedor E. The utility of the RoPE score in cryptogenic stroke patients ≤50 years in predicting a stroke-related patent foramen ovale. Int J Stroke. 2016;11(1):NP7-8. doi: 10.1177/1747493015607505.
Morais LA, Sousa L, Fiarresga A, Martins JD, Timóteo AT, Monteiro AV, Soares C, Agapito A, Pinto F, Ferreira RC. RoPE Score as a Predictor of Recurrent Ischemic Events After Percutaneous Patent Foramen Ovale Closure. Int Heart J. 2018;59(6):1327-1332.
Specialty: Neurology
System: Nervous
Objective: Diagnosis
No. Of Items: 6
Year Of Study: 2013
Abbreviation: RoPE
Article By: Denise Nedea
Published On: May 21, 2020 · 12:00 AM
Last Checked: May 21, 2020
Next Review: May 21, 2025