Prediction-Driven Decision Support for Patients With Mild Stroke: A Model Based on Machine Learning Algorithms.

Xinping Lin,Zhihong Zhao,Junshan Zhou,Fuping Jiang,Xiaoli Cui,Shiteng Lin,Jianjun Zou,Juan Zhang,Nihong Chen,Daizun Zou

doi:10.3389/fneur.2021.761092

Abstract

Background and Purpose: Treatment for mild stroke remains an open question. We aim to develop a decision support tool based on machine learning (ML) algorithms, called DAMS (Disability After Mild Stroke), to identify mild stroke patients who would be at high risk of post-stroke disability (PSD) if they only received medical therapy and, more importantly, to aid neurologists in making individual clinical decisions in emergency contexts.Methods: Ischemic stroke patients were prospectively recorded in the National Advanced Stroke Center of Nanjing First Hospital (China) between July 2016 and September 2020. The exclusion criteria were patients who received thrombolytic therapy, age <18 years, lack of 3-month modified Rankin Scale (mRS), disabled before the index stroke, with an admission National Institute of Health stroke scale (NIHSS) > 5. The primary outcome was PSD, corresponding to 3-month mRS ≥ 2. We developed five ML models and assessed the area under curve (AUC) of receiver operating characteristic, calibration curve, and decision curve analysis. The optimal ML model was selected to be DAMS. In addition, SHapley Additive exPlanations (SHAP) approach was introduced to rank the feature importance. Finally, rapid-DAMS (R-DAMS) was constructed for a more urgent situation based on DAMS.Results: A total of 1,905 mild stroke patients were enrolled in this study, and patients with PSD accounted for 23.4% (447). There was no difference in AUCs between the five models (ranged from 0.691 to 0.823). Although there was similar discriminative performance between ML models, the support vector machine model exhibited higher net benefit and better calibration (Brier score, 0.159, calibration slope, 0.935, calibration intercept, 0.035). Therefore, this model was selected for DAMS. In addition, SHAP approach showed that the most crucial feature was NIHSS on admission. Finally, R-DAMS was constructed and there was similar discriminative performance between R-DAMS and DAMS, but the former performed worse on calibration.Conclusions: DAMS and R-DAMS, as prediction-driven decision support tools, were designed to aid clinical decision-making for mild stroke patients in emergency contexts. In addition, even within a narrow range of baseline scores, NIHSS on admission is the strongest feature that contributed to the prediction.

Highlights

Around half of patients with ischemic stroke have mild neurological symptoms [1], usually with the expectation that such patients will come back to their pre-stroke activities regardless of the treatment
Our goal was to develop and validate a predictiondriven decision support tool based on machine learning (ML) algorithms, called DAMS (Disability After Mild Stroke), to early identify mild stroke patients who would be at high risk of poststroke disability (PSD) if they only received medical therapy, and more importantly, to assist neurologists to make individual clinical decisions for mild stroke patients
We demonstrated DAMS had the capacity to early identify mild stroke patients who would be at high risk of PSD if they only received medical therapy, achieving an optimal performance compared with our other ML models and previous scoring systems (THRIVE and HIAT scores)

Summary

Introduction

Around half of patients with ischemic stroke have mild neurological symptoms [1], usually with the expectation that such patients will come back to their pre-stroke activities regardless of the treatment. Over one-third of mild stroke patients present with some degree of poststroke disability (PSD) [2,3,4], which may be the result of inadequate acute treatments, early stroke recurrence, serious complications, or other reasons [1, 5]. For the acute treatment of mild stroke patients, the guidelines from the American Heart Association/American Stroke Association (AHA/ASA) [6] distinguish disabling from non-disabling stroke and recommend intravenous (IV) alteplase only for the former. We aim to develop a decision support tool based on machine learning (ML) algorithms, called DAMS (Disability After Mild Stroke), to identify mild stroke patients who would be at high risk of post-stroke disability (PSD) if they only received medical therapy and, more importantly, to aid neurologists in making individual clinical decisions in emergency contexts

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