Abstract
BACKGROUND: Posterior circulation infarction (POCI) is common. Imaging techniques such as non-contrast-CT (NCCT) and diffusion-weighted-magnetic-resonance-imaging commonly fail to detect hyperacute POCI. Studies suggest expert inspection of Computed Tomography Perfusion (CTP) improves diagnosis of POCI. In many settings, there is limited access to specialist expertise. Deep-learning has been successfully applied to automate imaging interpretation. This study aimed to develop and validate a deep-learning approach for the classification of POCI using CTP. METHODS: Data were analysed from 3541-patients from the International-stroke-perfusion-registry (INSPIRE). All patients with baseline multimodal-CT and follow-up imaging performed at 24-48 h were identified. A cohort of 541-patients was constructed on a 1:3 POCI-to -reference-ratio for model analysis. A 3D-Dense-Convolutional-Network (DenseNet) was trained to classify patients into POCI or non-POCI using CTP-deconvolved-maps. Six-stroke-experts also independently classified patients based upon stepwise access to multimodal CT (mCT) data. DenseNet results were compared against expert clinician results. Model and clinician performance was evaluated using area-under-the-receiver-operating-curve, sensitivity, specificity, accuracy and precision. Clinician agreement was measured with the Fleiss-Kappa-statistic. RESULTS: Best mean clinician diagnostic accuracy, sensitivity and agreement was demonstrated after review of all mCT data (AUC: 0.81, Sensitivity: 0.65, Fleiss-Kappa-statistic: 0.73). There was a spectrum of individual clinician results with an AUC-range of 0.73-0.86. Best DenseNet performance was recorded with an input combination of NCCT and delay-time maps. The DenseNet model was superior to the best mean clinician performance (AUC: 0.87) and was due to enhanced sensitivity (DenseNET: 0.77, Clinician: 0.65). The degree to which the DenseNet model outperformed each clinician ranged and was clinician specific (AUC improvement 0.01-0.14). CONCLUSION: Comprehensive review of CTP improves diagnostic performance and agreement amongst clinicians. A DenseNet model was superior to best mean clinician performance. The degree of improvement varied by specific clinician. Development of a clinician-DenseNet approach may improve inter-clinician agreement and diagnostic accuracy. This approach may alleviate limited specialist services in resource constrained settings.