Spatio-temporal deep learning for automatic detection of intracranial vessel perforation in digital subtraction angiography during endovascular thrombectomy

•Intracranial vessel perforation is a serious complication in EVT, procedural success may benefit from fast automated detection.•Automatic intracranial vessel perforation detection in DSA is studied for the first time.•Perforations are pooled from multiple (inter-)national clinical trials/registries.•Learning perforation progression characteristics as well as ensemble modeling improves performance.•The methods reach human expert level performance in perforation detection. [Display omitted] Intracranial vessel perforation is a peri-procedural complication during endovascular therapy (EVT). Prompt recognition is important as its occurrence is strongly associated with unfavorable treatment outcomes. However, perforations can be hard to detect because they are rare, can be subtle, and the interventionalist is working under time pressure and focused on treatment of vessel occlusions. Automatic detection holds potential to improve rapid identification of intracranial vessel perforation. In this work, we present the first study on automated perforation detection and localization on X-ray digital subtraction angiography (DSA) image series. We adapt several state-of-the-art single-frame detectors and further propose temporal modules to learn the progressive dynamics of contrast extravasation. Application-tailored loss function and post-processing techniques are designed. We train and validate various automated methods using two national multi-center datasets (i.e., MR CLEAN Registry and MR CLEAN-NoIV Trial), and one international multi-trial dataset (i.e., the HERMES collaboration). With ten-fold cross-validation, the proposed methods achieve an area under the curve (AUC) of the receiver operating characteristic of 0.93 in terms of series level perforation classification. Perforation localization precision and recall reach 0.83 and 0.70 respectively. Furthermore, we demonstrate that the proposed automatic solutions perform at similar level as an expert radiologist.