Faculty Bibliography

PURPOSE/UNASSIGNED:Vision loss following surgery for pituitary adenoma is poorly described in the literature and cannot be reliably predicted with current prognostic models. Detailed characterization of this population is warranted to further understand the factors that predispose a minority of patients to post-operative vision loss. MATERIALS AND METHODS/UNASSIGNED:The medical records of 587 patients who underwent endoscopic transsphenoidal surgery at the Mount Sinai Medical Centre between January 2013 and August 2018 were reviewed. Patients who experienced post-operative vision deterioration, defined by reduced visual acuity, worsened VFDs, or new onset of blurry vision, were identified and analysed. RESULTS/UNASSIGNED:Eleven out of 587 patients who received endoscopic surgery for pituitary adenoma exhibited post-operative vision deterioration. All eleven patients presented with preoperative visual impairment (average duration of 13.1 months) and pre-operative optic chiasm compression. Seven patients experienced visual deterioration within 24 h of surgery. The remaining four patients experienced delayed vision loss within one month of surgery. Six patients had complete blindness in at least one eye, one patient had complete bilateral blindness. Four patients had reduced visual acuity compared with preoperative testing, and four patients reported new-onset blurriness that was not present before surgery. High rates of graft placement (10/11 patients) and opening of the diaphragma sellae (9/11 patients) were found in this series. Four patients had hematomas and four patients had another significant post-operative complication. CONCLUSIONS/UNASSIGNED:While most patients with pituitary adenoma experience favourable ophthalmological outcomes following endoscopic transsphenoidal surgery, a subset of patients exhibit post-operative vision deterioration. The present study reports surgical and disease features of this population to further our understanding of factors that may underlie vision loss following pituitary adenoma surgery. Graft placement and opening of the diaphragma sellae may be important risk factors in vision loss following ETS and should be an area of future investigation.

OBJECTIVE:Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS:Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS:The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS:Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.

BACKGROUND AND PURPOSE/OBJECTIVE:Quantitative volumetric segmentation of gliomas has important implications for diagnosis, treatment, and prognosis. We present a deep-learning model that accommodates automated preoperative and postoperative glioma segmentation with a pipeline for clinical implementation. Developed and engineered in concert, the work seeks to accelerate clinical realization of such tools. MATERIALS AND METHODS/METHODS:A deep learning model, autoencoder regularization-cascaded anisotropic, was developed, trained, and tested fusing key elements of autoencoder regularization with a cascaded anisotropic convolutional neural network. We constructed a dataset consisting of 437 cases with 40 cases reserved as a held-out test and the remainder split 80:20 for training and validation. We performed data augmentation and hyperparameter optimization and used a mean Dice score to evaluate against baseline models. To facilitate clinical adoption, we developed the model with an end-to-end pipeline including routing, preprocessing, and end-user interaction. RESULTS:The autoencoder regularization-cascaded anisotropic model achieved median and mean Dice scores of 0.88/0.83 (SD, 0.09), 0.89/0.84 (SD, 0.08), and 0.81/0.72 (SD, 0.1) for whole-tumor, tumor core/resection cavity, and enhancing tumor subregions, respectively, including both preoperative and postoperative follow-up cases. The overall total processing time per case was ∼10 minutes, including data routing (∼1 minute), preprocessing (∼6 minute), segmentation (∼1-2 minute), and postprocessing (∼1 minute). Implementation challenges were discussed. CONCLUSIONS:We show the feasibility and advantages of building a coordinated model with a clinical pipeline for the rapid and accurate deep learning segmentation of both preoperative and postoperative gliomas. The ability of the model to accommodate cases of postoperative glioma is clinically important for follow-up. An end-to-end approach, such as used here, may lead us toward successful clinical translation of tools for quantitative volume measures for glioma.

The fundamental challenge in machine learning is ensuring that trained models generalize well to unseen data. We developed a general technique for ameliorating the effect of dataset shift using generative adversarial networks (GANs) on a dataset of 149,298 handwritten digits and dataset of 868,549 chest radiographs obtained from four academic medical centers. Efficacy was assessed by comparing area under the curve (AUC) pre- and post-adaptation. On the digit recognition task, the baseline CNN achieved an average internal test AUC of 99.87% (95% CI, 99.87-99.87%), which decreased to an average external test AUC of 91.85% (95% CI, 91.82-91.88%), with an average salvage of 35% from baseline upon adaptation. On the lung pathology classification task, the baseline CNN achieved an average internal test AUC of 78.07% (95% CI, 77.97-78.17%) and an average external test AUC of 71.43% (95% CI, 71.32-71.60%), with a salvage of 25% from baseline upon adaptation. Adversarial domain adaptation leads to improved model performance on radiographic data derived from multiple out-of-sample healthcare populations. This work can be applied to other medical imaging domains to help shape the deployment toolkit of machine learning in medicine.

Federated learning (FL) is a method used for training artificial intelligence models with data from multiple sources while maintaining data anonymity, thus removing many barriers to data sharing. Here we used data from 20 institutes across the globe to train a FL model, called EXAM (electronic medical record (EMR) chest X-ray AI model), that predicts the future oxygen requirements of symptomatic patients with COVID-19 using inputs of vital signs, laboratory data and chest X-rays. EXAM achieved an average area under the curve (AUC) >0.92 for predicting outcomes at 24 and 72 h from the time of initial presentation to the emergency room, and it provided 16% improvement in average AUC measured across all participating sites and an average increase in generalizability of 38% when compared with models trained at a single site using that site's data. For prediction of mechanical ventilation treatment or death at 24 h at the largest independent test site, EXAM achieved a sensitivity of 0.950 and specificity of 0.882. In this study, FL facilitated rapid data science collaboration without data exchange and generated a model that generalized across heterogeneous, unharmonized datasets for prediction of clinical outcomes in patients with COVID-19, setting the stage for the broader use of FL in healthcare.

STUDY DESIGN/METHODS:Retrospective analysis of prospectively acquired data. OBJECTIVE:The aim of this study was to identify interaction effects that modulate nonhome discharge (NHD) risk by applying coalitional game theory principles to interpret machine learning models and understand variable interaction effects underlying NHD risk. SUMMARY OF BACKGROUND DATA/BACKGROUND:NHD may predispose patients to adverse outcomes during their care. Previous studies identified potential factors implicated in NHD; however, it is unclear how interaction effects between these factors contribute to overall NHD risk. METHODS:Of the 11,150 reviewed cases involving procedures for degenerative spine conditions, 1764 cases (15.8%) involved NHD. Gradient boosting classifiers were used to construct predictive models for NHD for each patient. Shapley values, which assign a unique distribution of the total NHD risk to each model variable using an optimal cost-sharing rule, quantified feature importance and examined interaction effects between variables. RESULTS:Models constructed from features identified by Shapley values were highly predictive of patient-level NHD risk (mean C-statistic = 0.91). Supervised clustering identified distinct patient subgroups with variable NHD risk and their shared characteristics. Focused interaction analysis of surgical invasiveness, age, and comorbidity burden suggested age as a worse risk factor than comorbidity burden due to stronger positive interaction effects. Additionally, negative interaction effects were found between age and low blood loss, indicating that intraoperative hemostasis may be critical for reducing NHD risk in the elderly. CONCLUSION/CONCLUSIONS:This strategy provides novel insights into feature interactions that contribute to NHD risk after spine surgery. Patients with positively interacting risk factors may require special attention during their hospitalization to control NHD risk.Level of Evidence: 3.

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Real-time seizure detection is a resource intensive process as it requires continuous monitoring of patients on stereoelectroencephalography. This study improves real-time seizure detection in drug resistant epilepsy (DRE) patients by developing patient-specific deep learning models that utilize a novel self-supervised dynamic thresholding approach. Deep neural networks were constructed on over 2000 h of high-resolution, multichannel SEEG and video recordings from 14 DRE patients. Consensus labels from a panel of epileptologists were used to evaluate model efficacy. Self-supervised dynamic thresholding exhibited improvements in positive predictive value (PPV; difference: 39.0%; 95% CI 4.5-73.5%; Wilcoxon-Mann-Whitney test; N = 14; p = 0.03) with similar sensitivity (difference: 14.3%; 95% CI - 21.7 to 50.3%; Wilcoxon-Mann-Whitney test; N = 14; p = 0.42) compared to static thresholds. In some models, training on as little as 10 min of SEEG data yielded robust detection. Cross-testing experiments reduced PPV (difference: 56.5%; 95% CI 25.8-87.3%; Wilcoxon-Mann-Whitney test; N = 14; p = 0.002), while multimodal detection significantly improved sensitivity (difference: 25.0%; 95% CI 0.2-49.9%; Wilcoxon-Mann-Whitney test; N = 14; p < 0.05). Self-supervised dynamic thresholding improved the efficacy of real-time seizure predictions. Multimodal models demonstrated potential to improve detection. These findings are promising for future deployment in epilepsy monitoring units to enable real-time seizure detection without annotated data and only minimal training time in individual patients.

Purpose/UNASSIGNED:To train a deep learning classification algorithm to predict chest radiograph severity scores and clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Materials and Methods/UNASSIGNED:= 110) populations. Bootstrapping was used to compute CIs. Results/UNASSIGNED:The model trained on the chest radiograph severity score produced the following areas under the receiver operating characteristic curves (AUCs): 0.80 (95% CI: 0.73, 0.88) for the chest radiograph severity score, 0.76 (95% CI: 0.68, 0.84) for admission, 0.66 (95% CI: 0.56, 0.75) for intubation, and 0.59 (95% CI: 0.49, 0.69) for death. The model trained on clinical variables produced an AUC of 0.64 (95% CI: 0.55, 0.73) for intubation and an AUC of 0.59 (95% CI: 0.50, 0.68) for death. Combining chest radiography and clinical variables increased the AUC of intubation and death to 0.88 (95% CI: 0.79, 0.96) and 0.82 (95% CI: 0.72, 0.91), respectively. Conclusion/UNASSIGNED:© RSNA, 2020.