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

Clin Neurol Neurosurg. 2024 Oct:245:108437. doi: 10.1016/j.clineuro.2024.108437. Epub 2024 Jul 10.

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Keywords: Carotid artery web; Paradoxical embolization; Patent foramen ovale; Stroke etiology.

MeSH terms

  • Adult
  • Aged
  • Carotid Artery Diseases / complications
  • Carotid Artery Diseases / diagnostic imaging
  • Computed Tomography Angiography
  • Embolism, Paradoxical* / diagnostic imaging
  • Embolism, Paradoxical* / etiology
  • Female
  • Foramen Ovale, Patent* / complications
  • Foramen Ovale, Patent* / diagnostic imaging
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Factors
  • Stroke* / diagnostic imaging
  • Stroke* / etiology