DSA-NRP: No-Reflow Prediction From Angiographic Perfusion Dynamics in Stroke EVT

Following successful large-vessel recanalization via endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), some patients experience a complication known as no-reflow, defined by persistent microvascular hypoperfusion that undermines tissue recovery and worsens clinical outcomes. Although prompt identification is crucial, standard clinical practice relies on perfusion magnetic resonance imaging (MRI) within 24 hours post-procedure, delaying intervention. In this work, we introduce the first-ever machine learning (ML) framework to predict no-reflow immediately after EVT by leveraging previously unexplored intra-procedural digital subtraction angiography (DSA) sequences and clinical variables. Our retrospective analysis included AIS patients treated at UCLA Medical Center (2011-2024) who achieved favorable mTICI scores (2c or 3) and underwent pre- and post-procedure MRI. No-reflow was defined as a $\gt {15}\%$ reduction in relative cerebral blood volume or flow within the infarct core compared to the contralateral hemisphere. From DSA sequences (anteroposterior and lateral views), we extracted statistical and temporal perfusion features from the target downstream territory to train ML classifiers for predicting no-reflow. Our preliminary results demonstrate that this novel method outperformed a clinical-features baseline (AUROC: 0.9330 vs. 0.7768 ( ${p} = {0}.{006}$ )), suggesting that real-time DSA perfusion dynamics may encode clinically relevant information related to microvascular integrity. This approach establishes a preliminary foundation for immediate, accurate no-reflow prediction, enabling clinicians to proactively manage high-risk patients without reliance on delayed imaging, though it warrants validation in larger, independent cohorts.