Generalizable automated ischaemic stroke lesion segmentation with vision transformers

Ischaemic stroke, a leading cause of death and disability, critically relies on neuroimaging for characterising the anatomical pattern of injury. Diffusion-weighted imaging (DWI) provides the highest expressivity in ischemic stroke but poses substantial challenges for automated lesion segmentation: susceptibility artefacts, morphological heterogeneity, age-related comorbidities, time-dependent signal dynamics, instrumental variability, and limited labelled data. Current U-Net-based models therefore underperform, a problem accentuated by inadequate evaluation metrics that focus on mean performance, neglecting anatomical, subpopulation, and acquisition-dependent variability. Here, we present a high-performance DWI lesion segmentation tool addressing these challenges through optimized vision transformer-based architectures, integration of 3563 annotated lesions from multi-site data, and algorithmic enhancements, achieving state-of-the-art results. We further propose a novel evaluative framework assessing model fidelity, equity (across demographics and lesion subtypes), anatomical precision, and robustness to instrumental variability, promoting clinical and research utility. This work advances stroke imaging by reconciling model expressivity with domain-specific challenges and redefining performance benchmarks to prioritize equity and generalizability, critical for personalized medicine and mechanistic research.

Deep Learning-Driven Segmentation of Ischemic Stroke Lesions Using Multi-Channel MRI

Ischemic stroke, caused by cerebral vessel occlusion, presents substantial challenges in medical imaging due to the variability and subtlety of stroke lesions. Magnetic Resonance Imaging (MRI) plays a crucial role in diagnosing and managing ischemic stroke, yet existing segmentation techniques often fail to accurately delineate lesions. This study introduces a novel deep learning-based method for segmenting ischemic stroke lesions using multi-channel MRI modalities, including Diffusion Weighted Imaging (DWI), Apparent Diffusion Coefficient (ADC), and enhanced Diffusion Weighted Imaging (eDWI). The proposed architecture integrates DenseNet121 as the encoder with Self-Organized Operational Neural Networks (SelfONN) in the decoder, enhanced by Channel and Space Compound Attention (CSCA) and Double Squeeze-and-Excitation (DSE) blocks. Additionally, a custom loss function combining Dice Loss and Jaccard Loss with weighted averages is introduced to improve model performance. Trained and evaluated on the ISLES 2022 dataset, the model achieved Dice Similarity Coefficients (DSC) of 83.88% using DWI alone, 85.86% with DWI and ADC, and 87.49% with the integration of DWI, ADC, and eDWI. This approach not only outperforms existing methods but also addresses key limitations in current segmentation practices. These advancements significantly enhance diagnostic precision and treatment planning for ischemic stroke, providing valuable support for clinical decision-making.

Automated Segmentation of Ischemic Stroke Lesions in Non-Contrast Computed Tomography Images for Enhanced Treatment and Prognosis

Stroke is the second leading cause of death worldwide, and is increasingly prevalent in low- and middle-income countries (LMICs). Timely interventions can significantly influence stroke survivability and the quality of life after treatment. However, the standard and most widely available imaging method for confirming strokes and their sub-types, the NCCT, is more challenging and time-consuming to employ in cases of ischemic stroke. For this reason, we developed an automated method for ischemic stroke lesion segmentation in NCCTs using the nnU-Net frame work, aimed at enhancing early treatment and improving the prognosis of ischemic stroke patients. We achieved Dice scores of 0.596 and Intersection over Union (IoU) scores of 0.501 on the sampled dataset. After adjusting for outliers, these scores improved to 0.752 for the Dice score and 0.643 for the IoU. Proper delineation of the region of infarction can help clinicians better assess the potential impact of the infarction, and guide treatment procedures.

ISLES 2024: The first longitudinal multimodal multi-center real-world dataset in (sub-)acute stroke

Stroke remains a leading cause of global morbidity and mortality, placing a heavy socioeconomic burden. Over the past decade, advances in endovascular reperfusion therapy and the use of CT and MRI imaging for treatment guidance have significantly improved patient outcomes and are now standard in clinical practice. To develop machine learning algorithms that can extract meaningful and reproducible models of brain function for both clinical and research purposes from stroke images - particularly for lesion identification, brain health quantification, and prognosis - large, diverse, and well-annotated public datasets are essential. While only a few datasets with (sub-)acute stroke data were previously available, several large, high-quality datasets have recently been made publicly accessible. However, these existing datasets include only MRI data. In contrast, our dataset is the first to offer comprehensive longitudinal stroke data, including acute CT imaging with angiography and perfusion, follow-up MRI at 2-9 days, as well as acute and longitudinal clinical data up to a three-month outcome. The dataset includes a training dataset of n = 150 and a test dataset of n = 100 scans. Training data is publicly available, while test data will be used exclusively for model validation. We are making this dataset available as part of the 2024 edition of the Ischemic Stroke Lesion Segmentation (ISLES) challenge (https://www.isles-challenge.org/), which continuously aims to establish benchmark methods for acute and sub-acute ischemic stroke lesion segmentation, aiding in creating open stroke imaging datasets and evaluating cutting-edge image processing algorithms.

A Robust Ensemble Algorithm for Ischemic Stroke Lesion Segmentation: Generalizability and Clinical Utility Beyond the ISLES Challenge

Diffusion-weighted MRI (DWI) is essential for stroke diagnosis, treatment decisions, and prognosis. However, image and disease variability hinder the development of generalizable AI algorithms with clinical value. We address this gap by presenting a novel ensemble algorithm derived from the 2022 Ischemic Stroke Lesion Segmentation (ISLES) challenge. ISLES'22 provided 400 patient scans with ischemic stroke from various medical centers, facilitating the development of a wide range of cutting-edge segmentation algorithms by the research community. Through collaboration with leading teams, we combined top-performing algorithms into an ensemble model that overcomes the limitations of individual solutions. Our ensemble model achieved superior ischemic lesion detection and segmentation accuracy on our internal test set compared to individual algorithms. This accuracy generalized well across diverse image and disease variables. Furthermore, the model excelled in extracting clinical biomarkers. Notably, in a Turing-like test, neuroradiologists consistently preferred the algorithm's segmentations over manual expert efforts, highlighting increased comprehensiveness and precision. Validation using a real-world external dataset (N=1686) confirmed the model's generalizability. The algorithm's outputs also demonstrated strong correlations with clinical scores (admission NIHSS and 90-day mRS) on par with or exceeding expert-derived results, underlining its clinical relevance. This study offers two key findings. First, we present an ensemble algorithm (https://github.com/Tabrisrei/ISLES22_Ensemble) that detects and segments ischemic stroke lesions on DWI across diverse scenarios on par with expert (neuro)radiologists. Second, we show the potential for biomedical challenge outputs to extend beyond the challenge's initial objectives, demonstrating their real-world clinical applicability.

Input Data Adaptive Learning for Sub-acute Ischemic Stroke Lesion Segmentation

In machine learning larger databases are usually associated with higher classification accuracy due to better generalization. This generalization may lead to non-optimal classifiers in some medical applications with highly variable expressions of pathologies. This paper presents a method for learning from a large training base by adaptively selecting optimal training samples for given input data. In this way heterogeneous databases are supported two-fold. First, by being able to deal with sparsely annotated data allows a quick inclusion of new data set and second, by training an input-dependent classifier. The proposed approach is evaluated using the SISS challenge. The proposed algorithm leads to a significant improvement of the classification accuracy.

Local Gamma Augmentation for Ischemic Stroke Lesion Segmentation on MRI

The identification and localisation of pathological tissues in medical images continues to command much attention among deep learning practitioners. When trained on abundant datasets, deep neural networks can match or exceed human performance. However, the scarcity of annotated data complicates the training of these models. Data augmentation techniques can compensate for a lack of training samples. However, many commonly used augmentation methods can fail to provide meaningful samples during model fitting. We present local gamma augmentation, a technique for introducing new instances of intensities in pathological tissues. We leverage local gamma augmentation to compensate for a bias in intensities corresponding to ischemic stroke lesions in human brain MRIs. On three datasets, we show how local gamma augmentation can improve the image-level sensitivity of a deep neural network tasked with ischemic lesion segmentation on magnetic resonance images.

APIS: A paired CT-MRI dataset for ischemic stroke segmentation challenge

Stroke is the second leading cause of mortality worldwide. Immediate attention and diagnosis play a crucial role regarding patient prognosis. The key to diagnosis consists in localizing and delineating brain lesions. Standard stroke examination protocols include the initial evaluation from a non-contrast CT scan to discriminate between hemorrhage and ischemia. However, non-contrast CTs may lack sensitivity in detecting subtle ischemic changes in the acute phase. As a result, complementary diffusion-weighted MRI studies are captured to provide valuable insights, allowing to recover and quantify stroke lesions. This work introduced APIS, the first paired public dataset with NCCT and ADC studies of acute ischemic stroke patients. APIS was presented as a challenge at the 20th IEEE International Symposium on Biomedical Imaging 2023, where researchers were invited to propose new computational strategies that leverage paired data and deal with lesion segmentation over CT sequences. Despite all the teams employing specialized deep learning tools, the results suggest that the ischemic stroke segmentation task from NCCT remains challenging. The annotated dataset remains accessible to the public upon registration, inviting the scientific community to deal with stroke characterization from NCCT but guided with paired DWI information.

Self-Supervised Few-Shot Learning for Ischemic Stroke Lesion Segmentation

Precise ischemic lesion segmentation plays an essential role in improving diagnosis and treatment planning for ischemic stroke, one of the prevalent diseases with the highest mortality rate. While numerous deep neural network approaches have recently been proposed to tackle this problem, these methods require large amounts of annotated regions during training, which can be impractical in the medical domain where annotated data is scarce. As a remedy, we present a prototypical few-shot segmentation approach for ischemic lesion segmentation using only one annotated sample during training. The proposed approach leverages a novel self-supervised training mechanism that is tailored to the task of ischemic stroke lesion segmentation by exploiting color-coded parametric maps generated from Computed Tomography Perfusion scans. We illustrate the benefits of our proposed training mechanism, leading to considerable improvements in performance in the few-shot setting. Given a single annotated patient, an average Dice score of 0.58 is achieved for the segmentation of ischemic lesions.

Synchronous Image-Label Diffusion Probability Model with Application to Stroke Lesion Segmentation on Non-contrast CT

Stroke lesion volume is a key radiologic measurement for assessing the prognosis of Acute Ischemic Stroke (AIS) patients, which is challenging to be automatically measured on Non-Contrast CT (NCCT) scans. Recent diffusion probabilistic models have shown potentials of being used for image segmentation. In this paper, a novel Synchronous image-label Diffusion Probability Model (SDPM) is proposed for stroke lesion segmentation on NCCT using Markov diffusion process. The proposed SDPM is fully based on a Latent Variable Model (LVM), offering a complete probabilistic elaboration. An additional net-stream, parallel with a noise prediction stream, is introduced to obtain initial noisy label estimates for efficiently inferring the final labels. By optimizing the specified variational boundaries, the trained model can infer multiple label estimates for reference given the input images with noises. The proposed model was assessed on three stroke lesion datasets including one public and two private datasets. Compared to several U-net and transformer-based segmentation methods, our proposed SDPM model is able to achieve state-of-the-art performance. The code is publicly available.