Treatment of Patent Foramen Ovale in Adults Aged 18–60 with Cryptogenic Stroke and Low-Risk PFO

Clinical scenario

Age 18–60 Cryptogenic stroke Low-risk PFO (PASCAL)

This protocol applies to adults aged 18–60 who have experienced a cryptogenic stroke and are found to have a patent foramen ovale that lacks high-risk features — specifically, no large right-to-left shunt (≤20 bubbles in the left atrium on transoesophageal echocardiography) and no atrial septal aneurysm.

By PASCAL classification, stroke in this group is considered unlikely to be PFO-related, placing these patients in the low-risk category where the evidence does not support PFO closure unless there is a high probability of clinical causality.

Treatment approach

The recommended approach centres on medical therapy with an individualised choice of antithrombotic agent. The selection between available agent types takes into account each patient's bleeding risk profile and the estimated risk of stroke recurrence — the full structured regimen details the specific options and when each applies.

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References

The alternative to PFO closure is medical therapy which should be considered in low-risk patients without indications for PFO closure, and an assessment of bleeding risk versus the PFO-stroke related relapse risk should be made.

In patients aged 18–60 years with unlikely PFO-related stroke according to the PASCAL classification, the suggestion is against PFO closure unless there is a high probability of clinical causality enhancing the risk of paradoxical embolism.

Vitamin K antagonists (VKA) may be the best choice in low bleeding risk patients but requires good compliance and adequate monitoring.

Antiplatelet therapy is an alternative when the risk of stroke is low.

An individualised approach is suggested for the choice of antithrombotic therapy for patients with PFO-related stroke refusing PFO closure.

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