Symptomatic carotid webs and patent foramen ovale: RoPE score in competing stroke etiologies

• Published in: Clinical neurology and neurosurgery 2024-10, Vol.245, p.108437, Article 108437
• Main Authors: Alshaer, Qasem N., Landzberg, David Ross, Osehobo, Ehizele M., Koneru, Sitara, Karunamuni, Nilushi, Al-Bayati, Alhamza R., Grossberg, Jonathan A., Nahab, Fadi, Nogueira, Raul G., Allen, Jason W., Haussen, Diogo C.
• Format: Article
• Language: English
• Subjects: Angiography; Blood clots; Bubbles; Carotid arteries; Carotid artery; Carotid artery web; Computed tomography; Embolism; Embolization; Etiology; Hypertension; Ischemia; Paradoxical embolization; Patent foramen ovale; Risk factors; Stroke; Stroke etiology; Variables
• ISSN: 0303-8467; 1872-6968; 1872-6968
• DOI: 10.1016/j.clineuro.2024.108437

Patent foramen ovale (PFO)-associated stroke is diagnosed more frequently in young patients with infrequent vascular risk factors and embolic appearing infarcts. The risk of paradoxical embolism (RoPE) score is used to identify PFO-associated stroke. Patients with symptomatic carotid artery web (CaW) share a very similar risk profile and these lesions are frequently overlooked. In this study, we evaluate the RoPE score profile in patients with suspected symptomatic CaW. Retrospective analysis of prospectively collected data of patients with symptomatic CaW as the presumed cause of stroke presenting to 2 comprehensive stroke centers from 2014 to 2021. CaW was diagnosed using computed tomography angiography (CTA) of the neck & head. Shunt study was done using a transthoracic, transesophageal, and/or transcranial-Doppler with bubbles. RoPE score ≥7 was considered high. Seventy-five patients had stroke from a symptomatic ipsilateral CaW. Mean age was 49.7±11.2 years and 74.7 % were females. Median RoPE score was 7 [5–8], and 52.0 % had a high RoPE score. PFO was detected in 13.3 % of the patients and 20.5 % within the high RoPE score group. Ten percent of the cases would have been misclassified as PFO-associated strokes based on RoPE score. High RoPE scores were observed in the majority of patients with CaW-attributed stroke, and it should not be used to differentiate CaW- versus PFO-associated stroke. Careful extracranial internal carotid artery evaluation for CaW is warranted in cryptogenic strokes, including in PFO positive patients before defining stroke etiology. •Carotid artery webs (CaW) and patent foramen ovale (PFO) are stroke etiologies in the young that share a common risk profile.•RoPE score is used to identify stroke-related PFO.•Half of CaW patients have a high RoPE score, limiting its use in this population.•By depending solely on RoPE score, 10 % of patients with CaW will be misclassified as having PFO-related stroke.•Other risk stratification systems should be utilized in the setting of competing stroke etiologies.