Prognostic estimation for acute ischemic stroke patients undergoing mechanical thrombectomy within an extended therapeutic window using an interpretable machine learning model

BACKGROUND: Mechanical thrombectomy (MT) is effective for acute ischemic stroke with large vessel occlusion (AIS-LVO) within an extended therapeutic window. However, successful reperfusion does not guarantee positive prognosis, with around 40–50% of cases yielding favorable outcomes. Preoperative prediction of patient outcomes is essential to identify those who may benefit from MT. Although machine learning (ML) has shown promise in handling variables with non-linear relationships in prediction models, its “black box” nature and the absence of ML models for extended-window MT prognosis remain limitations. OBJECTIVE: This study aimed to establish and select the optimal model for predicting extended-window MT outcomes, with the Shapley additive explanation (SHAP) approach used to enhance the interpretability of the selected model. METHODS: A retrospective analysis was conducted on 260 AIS-LVO patients undergoing extended-window MT. Selected patients were allocated into training and test sets at a 3:1 ratio following inclusion and exclusion criteria. Four ML classifiers and one logistic regression (Logit) model were constructed using pre-treatment variables from the training set. The optimal model was selected through comparative validation, with key features interpreted using the SHAP approach. The effectiveness of the chosen model was further evaluated using the test set. RESULTS: Of the 212 selected patients, 159 comprised the training and 53 the test sets. Extreme gradient boosting (XGBoost) showed the highest discrimination with an area under the curve (AUC) of 0.93 during validation, and maintained an AUC of 0.77 during testing. SHAP analysis identified ischemic core volume, baseline NHISS score, ischemic penumbra volume, ASPECTS, and patient age as the top five determinants of outcome prediction. CONCLUSION: XGBoost emerged as the most effective for predicting the prognosis of AIS-LVO patients undergoing MT within the extended therapeutic window. SHAP interpretation improved its clinical confidence, paving the way for ML in clinical decision-making.