Association Between RoPE Score and PFO Grading on Bubble Echocardiography in Cryptogenic Stroke Patients: A Retrospective Cohort Study

SAEEDUR RAHMAN^1*Erik Hendrickson²Jamie Henderson¹Samuel McGrath³Ayah Mekhaimar¹Kishen Mathi¹Jake Hudson³Robert Sargent¹Brian Clapp³

• ¹Dartford And Gravesham NHS Trust, Dartford, United Kingdom
• ²University of California San Diego, La Jolla, United States
• ³Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Introduction Identifying high-risk anatomical and physiological features of a patent foramen ovale (PFO) is essential for selecting patients suitable for transcatheter device closure following cryptogenic stroke. Currently, no clinical screening tools exist to predict high-risk PFO features prior to transoesophageal echocardiography (TOE). Methods This retrospective cohort study, conducted in a stroke unit in South East England, included 130 patients aged ≤55 years diagnosed with ischaemic stroke or TIA of undetermined cause after initial evaluation. Of these, 83 were classed as cryptogenic. All underwent comprehensive investigations, including bubble echocardiography. The primary predictor, Risk of Paradoxical Embolism (RoPE) score, was examined for its association with significant PFO, defined as Model 1 (≥small) and Model 2 (≥moderate). Multivariable logistic regression models estimated adjusted odds ratios (aORs) between RoPE score and PFO presence. Results Among 130 patients, 47 had a known stroke aetiology, while 83 had cryptogenic stroke. Those with known aetiology showed higher rates of hypertension, hyperlipidaemia, and non-stenotic atherosclerosis. Cryptogenic stroke patients exhibited more cortical infarcts and higher RoPE scores. A lower RoPE score (≤5) was independently associated with known aetiology (aOR 3.91, p<0.01). Conversely, RoPE scores ≥6 were significantly linked to both small and moderate PFOs (aOR 5.39, p<0.01 and 15.95, p<0.01, respectively). Of 28 closure candidates, 20 underwent device closure—all with high RoPE scores and large PFOs. Discussion This study highlights the importance of a multidisciplinary approach in evaluating PFO-related stroke. Although PFOs occur in both cryptogenic and non-cryptogenic cases, their pathogenic relevance depends on clinical context. High RoPE scores (≥6) and cortical stroke patterns were independently associated with high-grade, clinically significant PFOs. Patients selected for device-closure consistently demonstrated high RoPE scores and multiple high-risk anatomical features, aligning with current international recommendations. Low RoPE scores (≤5) correlated strongly with alternative stroke mechanisms, supporting the RoPE score’s dual role in identifying likely PFO-related strokes and excluding embolic causes. Conclusion The RoPE score can help predict high-risk anatomical and physiological PFO features, aiding pre-TOE screening and minimizing unnecessary interventions. Larger prospective studies are warranted to validate and refine this approach.