PFO-Associated Stroke Causal Likelihood (PASCAL) Classification
Classifies how likely a PFO caused an otherwise cryptogenic ischaemic stroke (adults 18–60) by combining the RoPE score with high-risk PFO features, to guide PFO closure decisions.
Score interpretation
Low RoPE score and no high-risk PFO feature: no benefit from closure (HR 1.14) and more device-related atrial fibrillation (Kent 2021).
→ PFO closure generally not recommended; continue the search for another stroke mechanism and secondary prevention.
High RoPE score or a high-risk PFO feature: closure reduced recurrent stroke (HR 0.38; 2-year absolute risk reduction 2.1 %).
→ Shared decision with the stroke neurologist and cardiologist; closure is reasonable in selected patients.
High RoPE score and a high-risk PFO feature: largest benefit from closure (HR 0.10; 2-year absolute risk reduction 2.1 %).
→ Refer for percutaneous PFO closure after neurology–cardiology review.
Interpretation bands for the PASCAL PFO. Apply clinical judgement and local guidance.
References
- Kent DM 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(22):2277-2286.
- Elgendy AY, et al. Proposal for updated nomenclature and classification of potential causative mechanism in patent foramen ovale-associated stroke. JAMA Neurol. 2020;77(7):878-886.
- Mas JL et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke (CLOSE). N Engl J Med. 2017;377(11):1011-1021.
Related
Curated clinical cross-links plus same-class fallbacks.
- Edoxaban (AF Stroke Prevention / VTE) · Direct Factor Xa Inhibitor (DOAC)
- Clopidogrel (Stroke/TIA Secondary Prevention) · Antiplatelet (P2Y12 Inhibitor)
- Dabigatran (Stroke Prevention — AF) · Direct Oral Anticoagulant — Thrombin Inhibitor
- Rivaroxaban (Stroke Prevention — AF) · Direct Oral Anticoagulant — Factor Xa Inhibitor
- Edoxaban (Stroke Prevention) · Stroke Prevention
- Indomethacin (Patent Ductus Arteriosus) · NSAID — COX Inhibitor (PDA Closure in Neonates)
- Acute Heart Failure · ESC 2021 Heart Failure Guidelines; NICE NG106
- NSTEMI / Unstable Angina · ESC 2020 NSTEMI Guidelines; NICE NG185
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
- Hypertensive Emergency · ESC/ESH 2018 Hypertension Guidelines; NICE NG136
- Bradycardia Management · Resuscitation Council UK ABCDE; ESC 2021 Pacing Guidelines
- Ventricular Tachycardia / Fibrillation · Resuscitation Council UK ACLS; ESC 2022 Ventricular Arrhythmia Guidelines
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.