PFO Closure & Stroke Risk — ROPE Score Cutoff, PASCAL Score, Indications, Cryptogenic Stroke & PFO Occlusion

PFO Closure & Stroke Risk:

• What is PFO Closure & Stroke Risk?
• ROPE Score Cutoff
• PASCAL Score
• Indications
• Cryptogenic Stroke
• PFO Occlusion

What is PFO Closure & Stroke Risk?

PFO Closure & Stroke Risk refers to the clinical relationship between patent foramen ovale (PFO), a common congenital heart defect, and the risk of ischemic stroke, particularly cryptogenic stroke. A PFO is a small opening between the right and left atria of the heart that normally closes after birth but remains open in about 25% of adults. While often asymptomatic, a PFO can allow emboli (blood clots) to pass from the venous to the arterial circulation, potentially traveling to the brain and causing a stroke. This is referred to as a paradoxical embolism.

Over the past two decades, clinical trials and risk scores have been developed to identify patients most likely to benefit from PFO closure. Percutaneous closure devices are now commonly used for secondary stroke prevention in selected patients. Evaluating stroke risk in PFO involves tools like the ROPE and PASCAL scores, along with clinical judgment and imaging findings. Understanding when closure is indicated and which patients will benefit is critical for preventing recurrent strokes while avoiding unnecessary interventions.

ROPE Score Cutoff

The ROPE (Risk of Paradoxical Embolism) score is a clinical tool used to estimate the likelihood that a PFO is causally related to a patient’s cryptogenic stroke. The score is calculated based on factors such as age, history of hypertension, diabetes, stroke/TIA, smoking status, and cortical infarct location on imaging. The score ranges from 0 to 10, with higher scores indicating a greater probability that the PFO caused the stroke, and a lower risk of stroke recurrence from other causes.

A commonly used ROPE score cutoff is ≥7, which suggests a higher probability of a pathogenic PFO and supports consideration of closure. Scores below this threshold indicate a lower likelihood that the PFO is the stroke mechanism, meaning closure may offer less benefit. Importantly, the ROPE score does not account for anatomical PFO characteristics such as shunt size or atrial septal aneurysm, so it should be interpreted alongside echocardiographic findings and patient-specific clinical factors.

PASCAL Score

The PASCAL (PFO-Associated Stroke Causal Likelihood) score is a more recent tool designed to refine the assessment of PFO causality in cryptogenic stroke patients. Unlike the ROPE score, PASCAL incorporates both clinical and anatomical features, such as the presence of a large shunt, atrial septal aneurysm, and competing stroke mechanisms. The PASCAL score helps classify patients into categories such as “unlikely,” “possible,” “probable,” or “highly probable” PFO-related stroke.

By integrating anatomy and clinical risk, the PASCAL score addresses some of the limitations of the ROPE score. A higher PASCAL score indicates a stronger causal link between the PFO and stroke, supporting closure decisions. Clinicians often use both ROPE and PASCAL scores together to identify patients who may benefit most from intervention. This evidence-based approach helps optimize patient selection, improving outcomes while minimizing unnecessary procedures.

Indications

Indications for PFO closure are primarily focused on secondary prevention of stroke in carefully selected patients. Current guidelines recommend closure in patients aged 18 to 60 years with a cryptogenic ischemic stroke, a PFO with high-risk anatomical features (such as large shunt or atrial septal aneurysm), and no alternative stroke etiology. These criteria are based on randomized controlled trials such as RESPECT, CLOSE, and REDUCE, which demonstrated reduced stroke recurrence with closure plus antiplatelet therapy compared to medical therapy alone.

Other potential indications include decompression illness in divers, platypnea-orthodeoxia syndrome, and rare cases of refractory migraines with aura. However, stroke prevention remains the primary reason for closure. Decisions should be individualized and made in a multidisciplinary setting, including neurologists and cardiologists, to ensure appropriate patient selection and optimal timing.

Cryptogenic Stroke

Cryptogenic stroke refers to an ischemic stroke in which no clear etiology is identified after a thorough workup, including cardiac, vascular, and hematological evaluation. PFO is present in a higher proportion of patients with cryptogenic stroke compared to the general population, suggesting a potential causal role in some cases. These strokes typically occur in younger patients without traditional vascular risk factors.

Identifying a PFO in a cryptogenic stroke patient does not automatically mean it caused the stroke. Risk stratification using scores like ROPE and PASCAL, along with transesophageal echocardiography to assess PFO characteristics, helps determine causality. If the PFO is considered pathogenic, closure can significantly reduce the risk of recurrent stroke compared to medical therapy alone, as demonstrated in several major clinical trials.

PFO Occlusion

PFO occlusion is typically performed via a percutaneous transcatheter approach using a closure device. Under fluoroscopic and echocardiographic guidance, a catheter is introduced through the femoral vein to deliver and deploy the device across the PFO. Over time, endothelialization occurs, permanently sealing the foramen ovale. The procedure is minimally invasive, usually performed under local anesthesia with sedation, and patients typically return home the same or next day.

Post-closure management includes antiplatelet therapy (such as aspirin or clopidogrel) for several months to prevent thrombus formation on the device. Follow-up echocardiography ensures proper device placement and assesses for residual shunt. Complications are rare but can include atrial arrhythmias, device embolization, or thrombus formation. When performed in appropriately selected patients, PFO occlusion significantly reduces the risk of recurrent cryptogenic stroke, making it a key preventive strategy in modern stroke care.