PFO-Associated Stroke Causal Likelihood (PASCAL) Classification
Clinical classification system assessing likelihood that a patent foramen ovale (PFO) was the cause of cryptogenic stroke, to guide PFO closure decisions. Based on RoPE score and echocardiographic features.
Score interpretation
Low RoPE score and no high-risk features -- PFO likely incidental; pursue other stroke aetiology
→ Pursue alternative causes: prolonged cardiac monitoring for AF (implantable loop recorder if suspected); carotid imaging (CTA/MRA); hypercoagulable screen if < 50 years; anticardiolipin and beta-2 glycoprotein I antibodies (antiphospholipid); vasculitis screen; do not close PFO based on this profile; antiplatelet therapy (aspirin 75-100 mg OD); statin; BP optimisation; document PASCAL classification in neurology/cardiology notes.
Intermediate likelihood -- individualised decision required by stroke neurologist and cardiologist
→ Multidisciplinary neurology-cardiology stroke clinic assessment; present to combined MDT or stroke-neurology-cardiology conference; ESUS workup if not done; prolonged cardiac monitoring; assess patient age, stroke risk, procedural risk of closure; shared decision-making with patient; PFO closure if: age < 60, cryptogenic cortical infarct, large/high-risk PFO, patient preference after full counselling; if not closing: antiplatelet vs anticoagulation debate (evidence for anticoagulation limited -- CLOSURE I and PC trials negative for older devices).
High likelihood of causal PFO -- percutaneous closure indicated in eligible patients
→ Refer to structural cardiology for percutaneous PFO closure; CLOSE, REDUCE, DEFENSE-PFO trial inclusion: age <= 60 years, cryptogenic ischaemic stroke, PFO confirmed by TOE or ICE; pre-procedure: TEE/ICE for device sizing (AMPLATZER PFO Occluder or Helex); anticoagulation: aspirin + clopidogrel for 6 months post-procedure then aspirin alone for life; echocardiography at 6 months post-closure; risk of closure: 1-2% device-related AF, 0.1% thrombus; if age > 60 or not eligible for closure: anticoagulation may be considered (rivaroxaban or apixaban) or antiplatelet; annual neurology follow-up.
Interpretation bands for the PASCAL PFO. Apply clinical judgement and local guidance.
References
- Kent DM et al. The PFO International Consensus Study: developing an evidence-based approach to PFO management. JACC Cardiovascular Interventions. 2021;14(8):844-857.
- 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.