Proposed flexible clinical practice approach to classifying patent foramen ovale causal association in patients with embolic infarct topography and without other major stroke sources*

Risk source	Features	RoPE score
Risk source	Features	Low^¶	High^¶
Very high	A PFO and a straddling thrombus	Definite	Definite
High	(1) Concomitant pulmonary embolism or deep venous thrombosis preceding an index infarct combined with either (2a) a PFO and an atrial septal aneurysm or (2b) a large-shunt PFO	Probable	Highly probable
Medium	Either (1) a PFO and an atrial septal aneurysm or (2) a large-shunt PFO	Possible	Probable
Low	A small-shunt PFO without an atrial septal aneurysm	Unlikely	Possible

RoPE: Risk of Paradoxical Embolism; PFO: patent foramen ovale.
* The algorithm in this table is proposed for use in flexible clinical practice when application of an entire formal classification system is not being conducted.
¶ The RoPE score includes points for 5 age categories, cortical infarct, absence of hypertension, diabetes, prior stroke or transient ischemic attack, and smoking. A higher RoPE score (≥7 points) increases probability of causal association.

Reproduced with permission from: Elgendy AY, Saver JL, Amin Z, et al. Proposal for updated nomenclature and classification of potential causative mechanism in patent foramen ovale-associated Stroke. JAMA Neurol 2020; 77:878. Copyright © 2020 American Medical Association. All rights reserved.

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