Dual-phase vessel wall MRI deep learning for identifying composite unstable intracranial aneurysm phenotypes: a multicenter study

Objectives

To develop and externally validate a wall-focused deep learning framework for identifying composite unstable intracranial aneurysm phenotypes on dual-phase high-resolution vessel wall imaging (HR-VWI), and to visualize model attention on the aneurysm wall surface.

Methods

This retrospective multicenter study included patients with intracranial aneurysms who underwent both non-contrast and contrast-enhanced HR-VWI. Center 1 was used for model development and patient-level five-fold out-of-fold assessment, whereas Centers 2 and 3 served as independent external validation cohorts. For each aneurysm, dual-phase local wall patches and larger spatial context patches were generated. The Wall-Constrained Encoding Network (WCE-Net) extracted mask-constrained local wall features, and a transfer-learning U-Net with Nested Transformers (UNesT) branch extracted spatial context information. Branch outputs were fused by logit-level stacking. Model performance was evaluated using discrimination, calibration, and decision curve analysis. Three-dimensional gradient-weighted class activation mapping (Grad-CAM) responses were projected onto the reconstructed aneurysm wall surface and compared with HR-VWI surface signal intensity.

Results

A total of 629 patients with 773 aneurysms were included. The final fusion model achieved areas under the receiver operating characteristic curves (AUCs) of 0.908, 0.857, and 0.855 in Center 1, external Center 2, and external Center 3, respectively. Corresponding Brier scores were 0.119, 0.153, and 0.150. Surface Grad-CAM showed partial spatial overlap between model-attention hotspots and high-signal HR-VWI regions.

Conclusions

Dual-phase wall-focused local-context fusion showed feasibility for identifying composite unstable intracranial aneurysm phenotypes across centers. Surface Grad-CAM provided anatomically referenced visualization of model attention.

Key Points

Question

Can dual-phase high-resolution vessel wall imaging deep learning consistently identify composite unstable intracranial aneurysm phenotypes across internal and independent external cohorts?

Findings

The fusion model showed consistent discrimination across internal and independent external cohorts and enabled anatomically referenced visualization of model attention.

Critical Relevance Statement

External validation supports dual-phase wall-focused deep learning for cross-center vessel wall MRI assessment of composite unstable aneurysm phenotypes and anatomically referenced visualization of model attention.