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Purpose:  Accurate prediction of the progression to severe stroke in initially diagnosed nonsevere patients with acute–subacute anterior circulation nonlacuna ischemic infarction (ASACNLII) is important in making clinical decision. This study aimed to apply a machine learning method to predict if the initially diagnosed nonsevere patients with ASACNLII would progress to severe stroke by using diffusion-weighted images and clinical information on admission.   Methods:  This retrospective study enrolled 344 patients with ASACNLII from June 2017 to August 2020 on admission, and 108 cases progressed to severe stroke during hospitalization within 3–21 days. The entire data were randomized into a training set ( n  = 271) and an independent test set ( n  = 73). A U-Net neural network was employed for automatic segmentation and volume measurement of the ischemic lesions. Predictive models were developed and used for evaluating the progression to severe stroke using different feature sets (the volume data, the clinical data, and the combination) and machine learning methods (random forest, support vector machine, and logistic regression).   Results:  The U-Net showed high correlation with manual segmentation in terms of Dice coefficient of 0.806 and  R  2  value of the volume measurements of 0.960 in the test set. The random forest classifier of the volume + clinical combination achieved the best area under the receiver operating characteristic curve of 0.8358 (95% CI 0.7321–0.9269), and the accuracy, sensitivity, and specificity were 0.7780 (0.7397–0.7945), 0.7695 (0.6102–0.9074), and 0.8686 (0.6923–1.0), respectively. The Shapley additive explanation diagram showed the volume variable as the most important predictor.   Conclusion:  The U-Net was fully automatic and showed a high correlation with manual segmentation. An integrated approach combining clinical variables and stroke lesion volumes that were derived from the advanced machine learning algorithms had high accuracy in predicting the progression to severe stroke in ASACNLII patients.

Prediction of Progression to Severe Stroke in Initially Diagnosed Anterior Circulation Ischemic Cerebral Infarction