DSA Quantitative Analysis and Predictive Modeling of Obliteration in Cerebral AVM following Stereotactic Radiosurgery

Stereotactic radiosurgery is a key treatment modality for cerebral AVMs, particularly for small lesions and those located in eloquent brain regions. Predicting obliteration remains challenging due to evolving treatment paradigms and complex AVM presentations. With digital subtraction angiography (DSA) being the gold standard for outcome evaluation, radiomic approaches offer potential for more objective and detailed analysis. We aimed to develop machine learning modeling using DSA quantitative features for post-SRS obliteration prediction.

A prospective registry of patients with cerebral AVMs was screened to include patients with digital prestereotactic radiosurgery DSA. Anterior-posterior and lateral views were retrieved and manually segmented. Quantitative features were computed from the lesion ROI. Following feature selection, machine learning models were developed to predict unsuccessful 2-year total obliteration using processed radiomics features in comparison with clinical and radiosurgical features. When we evaluated through area under the receiver operating characteristic curve (AUROC), accuracy, area under the precision-recall curve F1, recall, and precision, the best performing model predictions on the test set were interpreted using the Shapley additive explanations approach.

DSA images of 100 included patients were retrieved and analyzed. The best-performing clinical radiosurgical model was a gradient boosting classifier with an AUROC of 68% and a recall of 67%. When we used radiomics variables as input, the AdaBoost classifier had the best evaluation metrics with an AUROC of 79% and a recall of 75%. The most important clinico-radiosurgical features, ranked by model contribution, were lesion volume, patient age, treatment dose rate, the presence of seizure at presentation, and prior resection. The most important ranked radiomics features were the following: gray-level size zone matrix, gray-level nonuniformity, kurtosis, sphericity, skewness, and gray-level dependence matrix dependence nonuniformity.

The combination of radiomics with machine learning is a promising approach for predicting cerebral AVM obliteration status following stereotactic radiosurgery. DSA could enhance prognostication of stereotactic radiosurgery-treated AVMs due to its high spatial resolution. Model interpretation is essential for building transparent models and establishing clinically valid radiomic signatures.