The RoPE Score and Right-to-Left Shunt Severity by Transcranial Doppler in the CODICIA Study

Abstract

Background: For patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), it is unknown whether the magnitude of right-to-left shunt (RLSh) measured by contrast transcranial Doppler (c-TCD) is correlated with the likelihood an identified PFO is related to CS as determined by the Risk of Paradoxical Embolism (RoPE) score. Additionally, for patients with CS, it is unknown whether PFO assessment by c-TCD is more sensitive for identifying RLSh compared with transesophageal echocardiography (TEE). Our aim was to determine the significance of RLSh grade by c-TCD in patients with PFO and CS. Methods: We evaluated patients with CS who had RLSh quantified by c-TCD in the Multicenter Study into RLSh in Cryptogenic Stroke (CODICIA) to determine whether there is an association between c-TCD shunt grade and the RoPE Score. For patients who underwent c-TCD and TEE, we determined whether there is agreement in identifying and grading RLSh between these two modalities. Results: The RoPE score predicted the presence versus the absence of RLSh documented by c-TCD (c-statistic = 0.66). For patients with documented RLSh by c-TCD, shunt severity was correlated with increasing RoPE score (rank correlation (r) = 0.15, p = 0.01). Among 293 patients who had both c-TCD and TEE performed, c-TCD was more sensitive (98.7%) for detecting RLSh. Of the 97 patients with no PFO identified on TEE, 28 (29%) had a large amount of RLSh seen on c-TCD. Conclusions: For patients with CS, severity of RLSh by c-TCD is positively correlated with the RoPE score, indicating that this technique for shunt grading identifies patients more likely to have pathogenic rather than incidental PFOs. c-TCD is also more sensitive in detecting RLSh than TEE. These findings suggest an important role for c-TCD in the evaluation of PFO in the setting of CS.

Right-to-left shunt detection using contrast-enhanced transcranial Doppler: A comparison of provocation maneuvers between coughing and a modified Valsalva maneuver

“…Several different categorization systems exist for RLS [3, 7, 14, 15]. Based on standards reported by Jauss et al ., Wessler et al ., and Xing et al .…”

“…Based on standards reported by Jauss et al ., Wessler et al ., and Xing et al . [7, 15, 16], a five-level categorization system was used in this study based on the appearance of MBs in the TCD spectrum using unilateral MCA monitoring as follows: Grade 0, negative; Grade I, 1 ≤ MBs ≤ 10; Grade II, 10 < MBs ≤ 25; Grade III, > 25 MBs and no curtain; and Grade IV, curtain where a single bubble cannot be identified (Fig 2). …”

Clinical and infarction patterns of PFO‐related cryptogenic strokes and a prediction model

“…First, we differentiate the cardiac and pulmonary shunt through controlling the time of appearance of microbubbles in the middle cerebral artery, and the signal change after the Valsalva maneuver 22. Second, according to c‐TCD, patients were first divided into five subgroups based on the number of microbubbles (MBs) observed: normal, no MBs; small, 1–9 MBs; moderate, 10–25 MBs; shower, >25 MBs; Curtain: uncountable 24. For 58 patients with MBs (>=small MB), we carried out TEE to exclude the intrapulmonary RLS (such as pulmonary arteriovenous fistula) and other reasons of intracardiac RLS (such as atrial septal defect, atrial septal aneurysm), and to confirm the existence of PFO 21, 25.…”

Patent foramen ovale and ischemic stroke: more shadows than lights? What the internist should know

“…Nonetheless, more recently, a large right to left shunt as determined by TCD has been shown to be corre- lated with a higher ROPE score meaning a plausible PFO related stroke and suggesting an important role for this diagnostic tool in identifying patients more likely to have a pathogenic rather than an incidental PFO. 33 Moreover echocardiographic features of the atrial septum such as septal hypermobility seem to be associated with a higher risk of recurrence only in patients with a high probability of a PFO related stroke (ROPE score >6). 34 Clinical predictors of paradoxical embolism through a PFO have also been reported in the literature such as a history of DVT/pulmonary embolism, recent prolonged travel, Valsalva maneuver preceding the neurological symptoms or waking up with stroke or TIA.…”