Standardized Evaluation of Automatic Methods for Perivascular Spaces Segmentation in MRI -- MICCAI 2024 Challenge Results

Perivascular spaces (PVS), when abnormally enlarged and visible in magnetic resonance imaging (MRI) structural sequences, are important imaging markers of cerebral small vessel disease and potential indicators of neurodegenerative conditions. Despite their clinical significance, automatic enlarged PVS (EPVS) segmentation remains challenging due to their small size, variable morphology, similarity with other pathological features, and limited annotated datasets. This paper presents the EPVS Challenge organized at MICCAI 2024, which aims to advance the development of automated algorithms for EPVS segmentation across multi-site data. We provided a diverse dataset comprising 100 training, 50 validation, and 50 testing scans collected from multiple international sites (UK, Singapore, and China) with varying MRI protocols and demographics. All annotations followed the STRIVE protocol to ensure standardized ground truth and covered the full brain parenchyma. Seven teams completed the full challenge, implementing various deep learning approaches primarily based on U-Net architectures with innovations in multi-modal processing, ensemble strategies, and transformer-based components. Performance was evaluated using dice similarity coefficient, absolute volume difference, recall, and precision metrics. The winning method employed MedNeXt architecture with a dual 2D/3D strategy for handling varying slice thicknesses. The top solutions showed relatively good performance on test data from seen datasets, but significant degradation of performance was observed on the previously unseen Shanghai cohort, highlighting cross-site generalization challenges due to domain shift. This challenge establishes an important benchmark for EPVS segmentation methods and underscores the need for the continued development of robust algorithms that can generalize in diverse clinical settings.

Calibrated Self-supervised Vision Transformers Improve Intracranial Arterial Calcification Segmentation from Clinical CT Head Scans

Vision Transformers (ViTs) have gained significant popularity in the natural image domain but have been less successful in 3D medical image segmentation. Nevertheless, 3D ViTs are particularly interesting for large medical imaging volumes due to their efficient self-supervised training within the masked autoencoder (MAE) framework, which enables the use of imaging data without the need for expensive manual annotations. intracranial arterial calcification (IAC) is an imaging biomarker visible on routinely acquired CT scans linked to neurovascular diseases such as stroke and dementia, and automated IAC quantification could enable their large-scale risk assessment. We pre-train ViTs with MAE and fine-tune them for IAC segmentation for the first time. To develop our models, we use highly heterogeneous data from a large clinical trial, the third International Stroke Trial (IST-3). We evaluate key aspects of MAE pre-trained ViTs in IAC segmentation, and analyse the clinical implications. We show: 1) our calibrated self-supervised ViT beats a strong supervised nnU-Net baseline by 3.2 Dice points, 2) low patch sizes are crucial for ViTs for IAC segmentation and interpolation upsampling with regular convolutions is preferable to transposed convolutions for ViT-based models, and 3) our ViTs increase robustness to higher slice thicknesses and improve risk group classification in a clinical scenario by 46%. Our code is available online.

Pre-processing and quality control of large clinical CT head datasets for intracranial arterial calcification segmentation

As a potential non-invasive biomarker for ischaemic stroke, intracranial arterial calcification (IAC) could be used for stroke risk assessment on CT head scans routinely acquired for other reasons (e.g. trauma, confusion). Artificial intelligence methods can support IAC scoring, but they have not yet been developed for clinical imaging. Large heterogeneous clinical CT datasets are necessary for the training of such methods, but they exhibit expected and unexpected data anomalies. Using CTs from a large clinical trial, the third International Stroke Trial (IST-3), we propose a pipeline that uses as input non-enhanced CT scans to output regions of interest capturing selected large intracranial arteries for IAC scoring. Our method uses co-registration with templates. We focus on quality control, using information presence along the z-axis of the imaging to group and apply similarity measures (structural similarity index measure) to triage assessment of individual image series. Additionally, we propose superimposing thresholded binary masks of the series to inspect large quantities of data in parallel. We identify and exclude unrecoverable samples and registration failures. In total, our pipeline processes 10,659 CT series, rejecting 4,322 (41%) in the entire process, 1,450 (14% of the total) during quality control, and outputting 6,337 series. Our pipeline enables effective and efficient region of interest localisation for targeted IAC segmentation.

Quality control for more reliable integration of deep learning-based image segmentation into medical workflows

Machine learning algorithms underpin modern diagnostic-aiding software, which has proved valuable in clinical practice, particularly in radiology. However, inaccuracies, mainly due to the limited availability of clinical samples for training these algorithms, hamper their wider applicability, acceptance, and recognition amongst clinicians. We present an analysis of state-of-the-art automatic quality control (QC) approaches that can be implemented within these algorithms to estimate the certainty of their outputs. We validated the most promising approaches on a brain image segmentation task identifying white matter hyperintensities (WMH) in magnetic resonance imaging data. WMH are a correlate of small vessel disease common in mid-to-late adulthood and are particularly challenging to segment due to their varied size, and distributional patterns. Our results show that the aggregation of uncertainty and Dice prediction were most effective in failure detection for this task. Both methods independently improved mean Dice from 0.82 to 0.84. Our work reveals how QC methods can help to detect failed segmentation cases and therefore make automatic segmentation more reliable and suitable for clinical practice.