RoPE Score Calculator for PFO in Cryptogenic Stroke
Calculate the Risk of Paradoxical Embolism (RoPE) score for cryptogenic stroke and PFO, with transparent age points, clinical factors, and interpretation limits.
Reviewed by Zaka Ahmed, MD Clinical reference · 6 min read
RoPE Score
For patients with a PFO after an otherwise cryptogenic ischemic stroke. Explicitly answer every item; none are preselected.
Educational use only. RoPE applies after a cryptogenic-stroke evaluation identifies a PFO. It does not independently prove causality, estimate closure benefit, or replace PFO anatomy and competing-mechanism assessment.
Clinical notes & interpretation Scoring guidance, pitfalls, FAQs, and references
The RoPE Score estimates how compatible a discovered PFO is with the clinical profile of a patient who has cryptogenic stroke.
- → Younger age, a cortical infarct, and absence of conventional vascular risk factors raise the score from 0 to 10.
- → RoPE is not a stand-alone causality test or PFO-closure indication; anatomy, competing mechanisms, and the complete workup still govern.
A patent foramen ovale is common, so finding one after a stroke does not prove it caused the event. The Risk of Paradoxical Embolism (RoPE) Score uses clinical features to describe how much the patient resembles people whose PFO is more likely to be stroke-associated rather than incidental.
At a glance · what the number changes
- 7–10. The phenotype in which a discovered PFO is more likely to be stroke-related than incidental — younger, cortical infarct, few conventional vascular risk factors.
- 0–6. The PFO is more likely incidental. Keep looking for another mechanism, including prolonged rhythm monitoring for occult atrial fibrillation.
- Higher is not “worse”. The high-RoPE phenotype carried a lower observed recurrence rate — it estimates attribution, not risk.
- It is not a closure decision. RoPE omits shunt size and atrial septal aneurysm, which is what the closure trials selected on.
- Order matters. Interpret only after a cryptogenic-stroke evaluation has actually found a PFO.
Reading the score
Higher scores describe younger patients with fewer conventional vascular risk factors and a cortical infarct. In the derivation cohorts, that profile was associated with a greater probability that the PFO was stroke-related, but paradoxically with a lower observed recurrence rate. That is why RoPE is better understood as a phenotype score than a simple “higher is worse” risk scale.
What RoPE leaves out
The score does not include high-risk PFO features such as large shunt or atrial septal aneurysm, venous thromboembolism, thrombophilia, prolonged rhythm monitoring, aortic arch disease, or occult malignancy. The PASCAL framework and current guidelines combine clinical phenotype with PFO anatomy and a rigorous exclusion of alternative mechanisms.
References.
- Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81:619–625. PubMed
- Kent DM, Saver JL, Kasner SE, et al. Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen ovale after stroke. JAMA. 2021;326:2277–2286. PubMed