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PFO-Associated Stroke Causal Likelihood (PASCAL) Classification System
Combines the RoPE score with high-risk PFO features to judge whether a PFO caused a stroke.
PFO-Associated Stroke Causal Likelihood (PASCAL) Classification System
Age
years
History of hypertension
History of diabetes
Prior stroke or TIA
Current smoker
Cortical infarct on imaging
High-risk PFO features (large right-to-left shunt, e.g. >=20 microbubbles on TEE/TCD, and/or atrial septal aneurysm with >=10 mm excursion)
Complete the fields above to see the result.
When to use
- Judging how likely a discovered patent foramen ovale is to have caused a cryptogenic stroke, to inform the closure-versus-medical-therapy discussion.
Formula
RoPE score (0-10) = age-band points (18-29:5, 30-39:4, 40-49:3, 50-59:2, 60-69:1, >=70:0) + 1 point each for absence of hypertension, absence of diabetes, absence of prior stroke/TIA, non-smoking status, and presence of a cortical infarct. A RoPE score >=7 is 'high'. PASCAL classifies the PFO-stroke relationship as Probable (high RoPE + high-risk features), Unlikely (low RoPE + no high-risk features), or Possible (either alone).
Pearls and pitfalls
- Developed from a pooled analysis of PFO-closure randomised trials to better select patients likely to benefit from closure.
- A high RoPE score reflects fewer competing (non-PFO) stroke risk factors, not certainty of causation.