PASCAL-Rope Score–Guided Patent Foramen Ovale Closure after Cryptogenic Stroke in a Very Young Adult: A Case Report
Jonathan Moyambi
*
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.
Ismael Al Fakihi
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.
Ndukute Fervent
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.
Kasongo Adolphe
Department of Cardiology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France.
Haboub Meryem
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Ibn Rochd University Hospital, Casablanca, Morocco.
Drighil Abdenasser
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Ibn Rochd University Hospital, Casablanca, Morocco.
*Author to whom correspondence should be addressed.
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic stroke; however, establishing a causal relationship remains challenging. Contemporary management relies on probabilistic stratification integrating clinical profile and high-risk interatrial anatomy like the presence of a highly mobile atrial septal aneurysm. The PFO-associated stroke causal likelihood (PASCAL) classification provides a structured framework to guide therapeutic decision-making, including percutaneous closure.
Case Presentation: A 23-year-old woman with no conventional cardiovascular risk factors, except active smoking and progestin-only contraception, presented with transient aphasia, frontal headache, and photophobia following physical exertion. Neurological symptoms resolved rapidly (NIHSS 0). Brain magnetic resonance imaging demonstrated a recent superficial left M3 middle cerebral artery infarction with an intraluminal thrombus. Intravenous thrombolysis was administered with favorable clinical and radiological evolution. Etiological assessment revealed a highly mobile atrial septal aneurysm on transthoracic echocardiography and a patent foramen ovale with a strongly positive right-to-left shunt on transesophageal contrast study. No alternative embolic source was identified on vascular imaging or prolonged rhythm monitoring.
Oral anticoagulation was initiated. Based on a high RoPE score combined with high-risk interatrial anatomy, the patient was classified as PROBABLE according to the PASCAL system, supporting a causal relationship between PFO and stroke. At five-month follow-up, successful percutaneous PFO closure was performed. Anticoagulation was discontinued and dual antiplatelet therapy initiated. Clinical follow-up remained uneventful, with no recurrent neurological events.
This case illustrates the clinical value of PASCAL-guided stratification in selecting very young patients with cryptogenic stroke for PFO closure and supports individualized secondary prevention strategies.
Keywords: Patent foramen ovale, cryptogenic stroke, young adult, risk assessment, paradoxical embolism, interventional, PASCAL classification