X-LMC: Cross-View Spatiotemporal Collateral Circulation Scoring from DSA

Digital subtraction angiography (DSA) is the reference standard for leptomeningeal collateral (LMC) assessment, providing critical prognostic insights to guide secondary treatment strategies, neurorehabilitation planning, and retrospective stroke research. However, clinical LMC grading via the ASITN/SIR scale relies on manual, highly variable visual inspection. We introduce X-LMC, a spatiotemporal framework for automated collateral scoring from time-resolved biplane DSA. The proposed architecture encodes spatial frame representations through a DINOv2 backbone, fuses orthogonal projections via a token-level cross-view attention module, and models representations of contrast bolus dynamics using a recurrent network architecture. We evaluate our framework on a multicenter dataset of 134 patients with M1-segment occlusions. In a 5-fold cross-validation setting, X-LMC yields higher point estimates than static architectures and spatiotemporal baselines adapted from related angiographic tasks, achieving a Quadratic Weighted Kappa (QWK) of 0.398 (vs. 0.322) and a dichotomized macro-F1 score of 0.711 (vs. 0.663) against the best-performing baseline. X-LMC performance also aligns with the observed clinical inter-rater agreement (QWK: 0.314). As the first DSA study attempting to automate LMC scoring, we demonstrate that multi-view temporal deep learning can capture collateral-specific contrast kinetics. Ultimately, these benchmarks delineate the clinical ambiguities and achievable performance boundaries of automated ASITN/SIR grading, establishing a reproducible foundation for objective hemodynamic phenotyping in stroke cohorts. Code is available at https://github.com/maedehafezi/X-LMC.

Leptomeningeal Collateral Detection on DSA via Vessel-Graph Neural Networks

Leptomeningeal collaterals (LMCs) are an important prognostic factor in acute ischemic stroke. Existing automated methods rely on CT angiography (CTA), but individual LMCs are often too small to be resolved on CTA, limiting these methods to coarse collateral scoring. Digital subtraction angiography (DSA) visualizes individual collaterals at superior resolution, yet current assessment remains subjective, relying on manual grading scales that suffer from poor inter-rater agreement. We present a framework that formulates collateral detection as the classification of individual vessel segments on a graph derived from DSA. A hybrid graph-pixel architecture combines a topology-aware graph branch with a dense pixel branch, fused in a shared node-probability space. In a five-fold cross-validation setting, the fused model achieves a PR-AUC of 0.434, outperforming the graph-only (0.403) and pixel-only (0.362) baselines. To our knowledge, this is the first method to enable the individualization of LMCs in DSA, allowing for precise per-vessel quantitative assessment. This integration shifts DSA assessment toward objective evaluation, supporting future biomarker and pattern discovery for individual LMCs.

Estimating Individualized Treatment Effects in Acute Ischemic Stroke with Causal Transformation Models (TRAM-DAG): A Multi-Centre Observational Study with External RCT Validation

Personalized medicine in acute ischemic stroke requires moving beyond average treatment effects (ATE) to individualized treatment effect (ITE) estimates to support treatment decisions. In acute ischemic stroke, mechanical thrombectomy has been shown to be more effective on average than lysis in randomized controlled trials (RCTs), such as the MR CLEAN study. We aim to identify which individual patients benefit most from mechanical thrombectomy compared to lysis. The outcome of interest is the modified Rankin Scale (mRS) at three months, an ordinal measure of functional disability (0: no symptoms, 6: death). We demonstrate that causal transformation models on directed acyclic graphs (TRAM-DAG) can be used for ITE estimation after being fitted on observational MAGIC multi-center stroke patient data. To ensure comparability with the MR CLEAN population, which we use for validation, we train the TRAM-DAG on a MAGIC sub-population with NIHSS at admission >= 6, corresponding to one inclusion criterion of MR CLEAN. The fitted model is then used to estimate ITEs for stroke patients in the MR CLEAN population. While these ITE estimates cannot be confirmed experimentally, we show that their average is consistent with the trial's reported ATE. Furthermore, the ITE estimates correctly rank trial patients by their observed frequency of a good outcome (mRS at three months <= 2). These findings support the use of causal models like TRAM-DAG for personalized decision-making in stroke care and highlight their ability to bridge the gap between observational evidence and clinical trials.