Zhenyu Wang ¹ Yuan Shen ^2* Xianxian Zhang ^2* Qingqing Li ³ Congsong Dong ^2* Shu Wang ^2* Haihua Sun ^2* Mingzhu Chen ² Xiaolu Xu ^2* PingLei Pan ^2* Zhenyu Dai ^1,2* Fei Chen ^2*

• ¹ School of Medicine, Nantong University, Nantong, Jiangsu Province, China
• ² Yancheng Third People's Hospital, Yancheng, China
• ³ Suzhou Wuzhong People’s Hospital, Suzhou, Jiangsu Province, China

Introduction: Early prognosis prediction of acute ischemic stroke (AIS) can support clinicians in choosing personalized treatment plans. The aim of this study is to develop a machine learning (ML) model that uses multiple post-labeling delay times (multi-PLD) arterial spin labeling (ASL) radiomics features to achieve early and precise prediction of AIS prognosis. Methods: This study enrolled 102 AIS patients admitted between December 2020 and September 2024. Clinical data, such as age and baseline National Institutes of Health Stroke Scale (NIHSS) score, were collected. Radiomics features were extracted from cerebral blood flow (CBF) images acquired through multi-PLD ASL. Features were selected using least absolute shrinkage and selection operator regression, and three models were developed: a clinical model, a CBF radiomics model, and a combined model, employing ten ML algorithms. Model performance was assessed using receiver operating characteristic curves and decision curve analysis (DCA). Shapley Additive exPlanations was applied to interpret feature contributions. Results: The combined model of extreme gradient boosting demonstrated superior predictive performance, achieving an area under the curve (AUC) of 0.876. Statistical analysis using the DeLong test revealed its significant outperformance compared to both the clinical model (AUC = 0.658, P < 0.001) and the CBF radiomics model (AUC = 0.755, P = 0.002). The robustness of all models was confirmed through permutation testing. Furthermore, DCA underscored the clinical utility of the combined model. The prognostic prediction of AIS was notably influenced by the baseline NIHSS score, age, as well as texture and shape features of CBF.The integration of clinical data and multi-PLD ASL radiomics features in a model offers a secure and dependable approach for predicting the prognosis of AIS, particularly beneficial for patients with contraindications to contrast agents. This model aids clinicians in devising individualized treatment plans, ultimately enhancing patient prognosis.