Abstract
OBJECTIVES: Complete reperfusion is the optimal technical goal of endovascular therapy (EVT) and is closely linked to favorable outcomes in acute ischemic stroke (AIS). This study developed and validated clot- and peri-clot-based radiomics models on pre-interventional dual-energy CT angiography (DE-CTA) to predict complete reperfusion and clinical outcome after EVT. MATERIALS AND METHODS: A total of 371 patients from three centers were retrospectively enrolled and assigned to training (n = 154), test (n = 66), and validation (n = 151) cohorts. Radiomics features from clot and peri-clot regions were extracted, and three machine learning models-clot-based, peri-clot-based, and combined-were constructed. Model performance for predicting complete reperfusion and 90-day outcome was assessed using AUC. RESULTS: Small, optimized feature subsets were selected for each model (11/11, 17/10, and 13/10 features for clot-based, peri-clot-based, and combined models for reperfusion and outcome prediction, respectively). For complete reperfusion, the peri-clot model showed the best performance with AUCs of 0.885 (95% CI: 0.834-0.937), 0.860 (95% CI: 0.771-0.948), and 0.847 (95% CI: 0.778-0.916) in the training, test, and validation cohorts, outperforming the clot-based (0.809, 0.759, 0.719) and combined models (0.867, 0.840, 0.820). A similar advantage was observed for outcome prediction, where the peri-clot model achieved the highest AUCs (0.854, 0.817, 0.850), exceeding the combined (0.839, 0.763, 0.804) and clot-based models (0.826, 0.709, 0.734). CONCLUSIONS: DE-CTA peri-clot radiomics provides superior prediction of both complete reperfusion and functional outcome after EVT, underscoring the clinical relevance of peri-clot microenvironment imaging and its potential to enhance pre-EVT patient selection and individualized prognostic evaluation. TRIAL REGISTRATION: The trial registration number (Chinese Clinical Trial Registry, ChiCTR2400092800) and date of registration (2024.11.22) were retrospectively registered. CRITICAL RELEVANCE STATEMENT: Peri-clot dual-energy computed tomography angiography radiomics outperformed clot-based models in multicenter external validation for predicting complete reperfusion and good 90-day functional outcome after endovascular therapy for acute ischemic stroke, supporting improved preprocedural risk stratification and patient selection. KEY POINTS: Complete reperfusion and functional recovery after endovascular thrombectomy remain hard to predict using thrombus features alone. Peri-clot radiomics on dual-energy computed tomography angiography achieved an external validation performance of 0.847 for complete reperfusion prediction. The same peri-clot model predicted 90-day functional outcome with 0.850 performance, supporting microenvironment-informed risk stratification. Peri-clot signatures consistently outperformed clot-only and combined models across multicenter cohorts, supporting robustness.