PASCAL-Rope Score–Guided Patent Foramen Ovale Closure after Cryptogenic Stroke in a Very Young Adult: A Case Report

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.