Prediction of response to thrombolysis in acute stroke using neural network analysis of CT perfusion imaging

Peer reviewed: TrueBackground:: In ischaemic stroke patients undergoing reperfusion therapy, the amount of salvageable tissue, that is, extent of the ischaemic penumbra, predicts the clinical outcomes. CT perfusion (CTP) enables quantification of penumbral tissues to guide decision making, and current programmes have automated its analysis. More advanced machine learning techniques utilising the CTP maps may improve prediction beyond the ischaemic volume measures. Method:: We determined whether applying convolutional neural networks (CNN), a key machine learning technique in modelling image-label relationships, to post-processed CTP maps improved prediction of outcome, assessed by 3 months modified Rankin scale (mRS). Patients who underwent thrombolysis but not thrombectomy were included. CTP maps of a retrospective cohort of 230 patients with middle cerebral artery stroke were used to develop the model, which was validated in an independent cohort of 129 patients. Results:: We constructed a CNN model that predicted a favourable post-thrombolysis outcome (mRS 0–2 at 3 months) with an area under receiver-operator characteristics curve (AUC) of 0.792 (95% CI, 0.707–0.877). This model outperformed a currently clinically used MISTAR software using previously validated thresholds (AUC = 0.583, 95% CI, 0.480–0.686) and a model modified using thresholds from the derivation cohort (AUC = 0.670, 95% CI, 0.571–0.769). By combining CNN-derived features and baseline demographic features, the prediction AUC was improved to 0.865 (95% CI, 0.794–0.936). Conclusion:: CNN improved prediction of post-thrombolysis outcome, and may be useful in selecting which patients benefit from thrombolysis