4454 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO.
9, SEPTEMBER 2023
A Deep Learning Model for Automatic
Segmentation of Intraparenchymal and
Intraventricular Hemorrhage for Catheter
Puncture Path Planning
Guoyu Tong , Xi Wang, Huiyan Jiang , Anhua Wu , Wen Cheng , Xiao Cui, Long Bao,
Ruikai Cai, and Wei Cai
Abstract—Intracerebral hemorrhage is the subtype of
stroke with the highest mortality rate, especially when it
also causes secondary intraventricular hemorrhage. The
optimal surgical option for intracerebral hemorrhage re-
mains one of the most controversial areas of neurosurgery.
We aim to develop a deep learning model for the au-
tomatic segmentation of intraparenchymal and intraven-
tricular hemorrhage for clinical catheter puncture path
planning. First, we develop a 3D U-Net embedded with a
multi-scale boundary aware module and a consistency loss
Manuscript received 8 February 2023; revised 7 May 2023 and 28
May 2023; accepted 9 June 2023. Date of publication 13 June 2023;
date of current version 6 September 2023. This work was supported in
part by the National Key Research and Development Program of China
under Grant 2020AAA0109400, in part by the Natural Science Foun-
dation of Liaoning Province under Grant 2021-YGJC-07, in part by the
National Natural Science Foundation of China under Grant 61872075,
in part by the Science and Technology Planning Project of Liaoning
Province under Grants 2021JH1/10400049 and 2022JH1/10400004, in
part by the Shenyang Medical-Industry Integration Collaborative Inno-
vation Research Project under Grant 21-172-9-02, and in part by the
345 talent Project of Shengjing Hospital. (Guoyu Tong and Xi Wang
contributed equally to this work.) (Corresponding authors: Huiyan Jiang;
Anhua Wu; Wen Cheng.)
Approval of all ethical and experimental procedures and protocols was
granted by the Institutional Review Board (IRB) of The First Affiliated
Hospital of China Medical University under Approval No. 2021-364-2.
Guoyu Tong and Xi Wang are with the Software College, Northeastern
University, Shenyang 110819, China, and also with the Neusoft Re-
search of Intelligent Healthcare Technology, Company Ltd., Shenyang
110004, China (e-mail: 2010499@stu.neu.edu.cn; wxi@neusoft.com).
Huiyan Jiang is with the Software College, Northeastern University,
Shenyang 110819, China, and also with the Key Laboratory of Intelli-
gent Computing in Medical Image, Ministry of Education, Northeastern
University, Shenyang 110819, China (e-mail: hyjiang@mail.neu.edu.cn).
Anhua Wu, Wen Cheng, and Ruikai Cai are with the Depart-
ment of Neurosurgery, Shengjing Hospital of China Medical Uni-
versity, Shenyang 110055, China (e-mail: wuanhua@yahoo.com;
cmu071207@163.com; caikelelele@gmail.com).
Xiao Cui is with the Department of Neurosurgery, The First Hos-
pital of China Medical University, Shenyang 110001, China (e-mail:
cuixiaocmu1h@126.com).
Long Bao is with the Department of Neurosurgery, The First Affiliated
Hospital of Jinzhou Medical University, Jinzhou 121002, China (e-mail:
514165983@qq.com).
Wei Cai is with the Neusoft Research of Intelligent Healthcare Tech-
nology, Company Ltd., Shenyang 110004, China (e-mail: cai.wei@
neusoft.com).
Network files can be accessed through https://github.com/
LL19920928/Segmentation-of-IPH-and-IVH.
Digital Object Identifier 10.1109/JBHI.2023.3285809
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for segmenting two types of hematoma in computed to-
mography images. The multi-scale boundary aware mod-
ule can improve the model’s ability to understand the two
types of hematoma boundaries. The consistency loss can
reduce the probability of classifying a pixel into two cate-
gories at the same time. Since different hematoma volumes
and locations have different treatments. We also measure
hematoma volume, estimate centroid deviation, and com-
pare with clinical methods. Finally, we plan the puncture
path and conduct clinical validation. We collected a total
of 351 cases, and the test set contained 103 cases. For
intraparenchymal hematomas, the accuracy can reach 96%
when the proposed method is applied for path planning.
For intraventricular hematomas, the proposed model’s seg-
mentation efficiency and centroid prediction are superior
to other comparable models. Experimental results and clin-
ical practice show that the proposed model has potential
for clinical application. In addition, our proposed method
has no complicated modules and improves efficiency, with
generalization ability.
Index Terms—Intracerebral hemorrhage segmentation,
Deep learning, Intraparenchymal hemorrhage, Intraventri-
cular hemorrhage, Catheter routing.
I. INTRODUCTION
NTRACEREBRAL hemorrhage (ICH) is the most com-
I mon type of hemorrhagic stroke, accounting for 15% of all
strokes. The morbidity and mortality of ICH are higher than that
of all stroke subtypes, as high as 40% to 50%. When secondary
intraventricular hemorrhage (IVH) is caused, the results are even
worse, with estimated mortality ranging from 50% to 80% [1].
The optimal management of ICH remains one of the most contro-
versial areas in neurosurgery. Recent exploration of minimally
invasive surgery for ICH and IVH, including catheter-based and
mechanical approaches, has shown great promise [2]. Directed
catheter drainage is considered to have a positive clinical prog-
nosis [3]. Most patients have reported cessation of bleeding
within 2 hours of the onset of ICH, but rebleeding frequently
occurs [4]. Animal experiments have shown that the optimal
time window for minimally invasive treatment is 6-12 hours
after bleeding [5]. Therefore, it is necessary to perform computed
tomography (CT) or magnetic resonance imaging (MRI) as soon
as possible after consultation. Although MRI is helpful in the
TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE
differential diagnosis of ICH, it is not the first choice. CT is
more sensitive and efficient, and is often the first choice for the
diagnosis of cerebral hemorrhage. Directional catheterization
under CT [6] greatly reduces hematoma and iatrogenic injury,
which can be demonstrated by DTI imaging [7]. In this study,
we focus on the segmentation of intraparenchymal hematoma
(IPH) and secondary IVH in CT images. Accurate segmentation
of hematoma helps to determine parameters such as volume,
location, shape, and centroid of hematoma, which are necessary
references for external ventricular drain (EVD) in clinical prac-
tice [8], [9], [10]. Therefore, fast and accurate segmentation of
IPH and IVH is an important prerequisite for minimally invasive
catheter therapy.
Recently, more and more researchers are paying attention to
the segmentation of ICH-related diseases. These segmentation
methods are mainly divided into traditional methods and deep
learning methods. Traditional methods include ellipse fitting
and wavelet decomposition [11], thresholding and morpholog-
ical operations [12], image texture [13], and so on. However,
traditional methods are difficult to achieve ideal results in
complex scenes and have poor generalization. Therefore, many
researchers have recently started to use deep learning methods
to solve such problems. Xu et al. proposed an automatic deep
learning method to quantify hematoma [14]. Ironside et al.
utilized U-Net [15] to automatically segment ICH and estimate
hematoma volume [16]. Schmitt et al. used a deep learning
model to detect and segment ICH and quantitatively assess
the volume of hematoma [17]. Mohammed et al. proposed a
two-stage ensemble method for the segmentation of cerebral
microbleeds, where the first stage detects potential hemorrhagic
regions and the second stage reduces mis-segmentation [18]. Shi
et al. used 3D U-Net [19] to detect aneurysms and compare the
segmentation results of the model with the annotation results
of radiologists and neurosurgeons [20]. Yu et al. developed
a dimension reduction U-Net [15] to segment IPH, subdural
hemorrhage, and intradural hemorrhage, and compared the seg-
mentation results of the model with the manual segmentation
results of clinicians, indicating that the model has potential for
clinical application [21]. Li et al. used the similarity between
slices to segment ICH, inferring the hemorrhage area of the target
slice based on the hemorrhage area of two adjacent slices [22].
Dhar et al. used a deep learning approach to quantify the volume
of ICH and its surrounding edema and obtain pixel-wise seg-
mentation results [23]. Li et al. exploited the symmetry of brain
structure to segment and detect ICH, and utilized the generative
adversarial networks (GAN) and dilated convolution [24] to
improve segmentation efficiency [25]. Kwon et al. proposed to
utilize feature differences between healthy templates and input
images for segmentation [26]. Arab et al. proposed a U-Net [15]
with depth supervision to quantify hematoma, correcting the
hemorrhage area from multiple scales [27].
However, in our survey, we rarely found researchers focused
on distinguishing between IPH and IVH. Automatic and accurate
segmentation of IPH and IVH is a very challenging task. This
task has two difficulties. First, there are no public datasets. Med-
ical data is difficult to obtain and annotate, making it difficult to
form large-scale datasets. By adding some complex modules, the
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4455
performance on a specific test set can be improved, but this will
also affect the model’s generalization ability, making it difficult
to apply in practice. Secondly, secondary IVH is generally
formed by IPH breaking into the brain ventricle. Therefore, the
Hounsfield unit (HU) value and texture features of IPH and IVH
are consistent. It increases the difficulty of segmentation. Fur-
thermore, it is difficult to obtain accurate centroids based on poor
segmentation results, leading to deviations in catheter puncture
path planning and failure of minimally invasive procedures.
In this study, we collected patients from the First Affiliated
Hospital of China Medical University and organized them into a
dataset of 351 cases with 50,432 slices. We propose a deep learn-
ing model based on 3D U-Net [19] to automatically segment
IPH and IVH, including a multi-scale boundary aware module
(MBAM) and consistency loss. The multi-scale boundary aware
module can learn the boundaries of the two types of hematomas
from multiple scales so that the model can distinguish the two
types of hematomas. The consistency loss can constrain the
model to divide a pixel into two categories at the same time,
reducing the false positives. We then compared the model’s seg-
mentation performance against a reference standard for manual
segmentation by neurosurgeons. We also quantitatively assessed
the hematoma volume obtained from the model and compared
it with the clinical hematoma volume measurement method.
Finally, we quantify the centroid deviation obtained from the
segmentation results and show the puncture path planned for
the IPH.
The main contributions of this article are as follows:
1. We propose a 3D U-Net based generalized automatic seg-
mentation model for intraparenchymal and intraventricu-
lar hematomas and compare it with a reference standard
for manual segmentation by neurosurgeons.
2. We quantitatively assessed the hematoma volume ob-
tained by the model and compared it with the clinical
hematoma volume measurement method.
3. We evaluate the hematoma centroid bias and demon-
strate the puncture path of catheter surgery with different
segmentation efficiencies, validating the potential of the
proposed model for clinical application.
4. The proposed method is simple and effective. In the
clinical test data, it is shown that the proposed method
can be generalized.
II. DATASETS
A. Data Information
We collected raw head CT images from the First Affiliated
Hospital of China Medical University for a retrospective study.
We collected 50,432 head CT slices from 351 patients in two
tranches. The first batch of data was collected from 2017.12.4
to 2021.3.17, including 34,513 slices from 248 patients, of
which 158 patients had IVH. The minimum number of slices
for a patient is 104 and the maximum number of slices is
399. The second batch of data was collected from 2021.8.28 to
2021.11.29, including 15,919 slices from 103 patients, of which
61 patients had IVH. The minimum number of slices is 104 and
the maximum number of slices is 352. The spacing of the z is
4456 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO. 9, SEPTEMBER 2023
Fig. 1. Flow of surgical path planning and the proposed network architecture.
TABLE I
DATA INFORMATION
1.0 mm. The spacing of the x and y axes is consistent, from
0.4375 to 0.625. The resolution of the slice is 512 × 512. CT
images were acquired using a GE Discovery NM/CT 750HD
scanner and a Philips Brilliance 64 scanner. Exposure parameters
were 120 kV and 400 mAs. More information about the dataset
is shown in Table I.
B. Ground Truth
Annotation of the hematoma was performed in two stages.
First, it was marked using 3D Slicer 4.10.2 [28] by two inter-
mediate neurosurgeons who had access to all DICOM series,
original reports, and clinical histories. When the two observers
disagreed, such as severe adhesion of IPH and IVH, a senior
neurosurgeon was assisted to solve the problem. Based on the
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joint reading, they used ITK-SNAP 3.8 [29] to perform slice-
by-slice revisions and confirm the hematoma contour and class
to generate final labels.
III. METHODS
In this section, we detail the data preprocessing, the proposed
model, and the data post-processing. We first introduce data
preprocessing and data augmentation methods. We then detail
the 3D U-Net [19] based network structure and how dilated con-
volutions [24] are exploited to gain boundary-aware capabilities.
Next, we introduce the proposed consistency loss, which aims
to reduce the number of pixels that are simultaneously predicted
as two classes. Finally, we describe the post-processing method.
The network architecture proposed in this article and the flow of
surgical path planning are shown in Fig. 1. The overall scheme of
surgical path planning includes the acquisition of DICOM data,
hematoma segmentation, 3D correction, cerebrospinal fluid de-
tection, cerebral falx detection, puncturable area detection, and
surgical path planning. A good hematoma segmentation result
is an important prerequisite for the subsequent steps. Therefore,
hematoma segmentation is a crucial part of minimally invasive
catheter surgery for intracerebral hemorrhage.
A. Data Preprocessing
We divide the first batch of data into a training set and a
validation set in a ratio of 7:3. The second batch of data is
all used as the test set. We first adjusted the window width
TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE
Fig. 2. Typical breaking point.
and level of all CT images to [−100, 200], then calculated the
mean and variance of training set images, and normalized all
CT images using Z-Score normalization. Then, all CT spacings
were resampled to [0.5, 0.5, 1] using trilinear interpolation. If
the size of the image after resampling exceeds 512 × 512, we
will crop the black borders outside the image. If the size is less
than 512 × 512, we will pad 0 to ensure that all images are of
size 512. During the training phase, we randomly apply flips
(horizontal or vertical) and random angle rotations (90, 180,
or 270 degrees) to each input tuple (CT and ground truth) for
standard online data augmentation. During the inference phase,
we did not apply any data augmentation strategy. The order of
training samples is re-randomized at each epoch.
There was no significant difference in HU value and texture
characteristics between IPH and IVH. The difference between
IPH and IVH is the physiological location of the hematoma. The
brain ventricle consists of two lateral brain ventricles, the third
brain ventricle, and the fourth brain ventricle. IVH forms when
IPH breaks into the brain ventricle. The IPH usually enters the
brain ventricle through one or several breaking points, forming
one or more hematomas. Therefore, the important information
to distinguish between IPH and IVH is to combine the adjacent
slices to find the boundary area and the breaking point of the two
types of hematoma. A typical breaking point is shown in Fig. 2.
A breaking point is shown in Fig. 2(a). Red represents IPH and
green represents IVH. Fig. 2(b), (c), and (d) show 3D views
in 3 axes. Fig. 2(e), (f), and (g) show 2D views in 3 axes. From
Fig. 2, it can be found that the two types of hematoma are directly
connected at the breaking point, and there are obvious bound-
aries at other locations. Therefore, if we want to separate the
two types of hematoma, we need to combine the breaking point
and boundary information of the two types of hematoma in the
3D space. When using the traditional 2D network preprocessing
method, the raw data will be input into the network slice by slice.
It will lose important contextual information. In addition, even
if the two types of hematoma can be separated when judging
whether a hematoma belongs to IPH or IVH, it is necessary to
combine the relative position information of the hematoma in the
whole slice, since the spatial position of the brain parenchyma
and the brain ventricle in the head is relatively fixed. When using
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4457
Fig. 3. Multi-scale boundary aware module.
traditional 3D network preprocessing, the raw data is cropped
into 3D blocks. These 3D blocks lose global information. When
there are both IPH and IVH in a 3D block, the model will not
be able to determine which part of the hematoma belongs to the
IPH and IVH. Therefore, in the training phase, we randomly
crop 8 consecutive slices of the CT image as 3D blocks as input.
In the inference stage, we sequentially crop 8 consecutive slices
of the CT image as 3D blocks as input.
B. Network Architecture method
We developed a 3D U-Net [19] based model that embeds
a multi-scale boundary aware module and a consistency loss
(MBA-UNet) for segmenting IPH and IVH from CT images
and assessing hematoma volume and centroid for catheter sur-
gical path planning. In the training phase, we randomly crop 8
consecutive slices as 3D blocks as the input of MBA-UNet. In
the inference phase, we sequentially crop 8 consecutive slices as
3D blocks as the input of MBA-UNet. The output of MBA-UNet
contains 3 channels in total. Among them, the first channel is
the prediction result of IPH, and we use Fiph ∈ R1×512×512×8 to
represent it. The second channel is the prediction result of IVH,
we use Fivh ∈ R1×512×512×8 to represent it. The third channel
is the prediction result of ICH, we use Fich ∈ R1×512×512×8 to
represent it. MBA-UNet adopts an encoder-decoder architecture
similar to 3D U-Net, which consists of an encoding module
for abstracting contextual information and a symmetric decod-
ing module for expanding encoded features into full-resolution
feature maps. To enlarge the receptive field of the network,
we downsample 4 times. At the last downsampling layer, we
use max pooling with kernel and stride of size (2, 2, 1) for
downsampling. Similarly, in the first upsampling layer, we use
deconvolution with kernel and stride of size (2, 2, 1) for upsam-
pling.
1) Multi-Scale Boundary Aware Module: We embedded a
multi-scale boundary aware module on the top layer of the en-
coder, which utilizes dilated convolutions with different dilation
rates to capture the boundaries of both types of hematomas, as
shown in Fig. 3. The HU value of the hematoma area is generally
higher than that of the brain parenchyma and brain ventricle.
4458 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO. 9, SEPTEMBER 2023
Since the characteristics of IPH and IVH are almost the same,
how to judge the boundary between IPH and IVH is a difficult
problem. In (e)–(h) of Fig. 3, the small red squares represent
dilated convolutions with different dilation rates, and the red
squares can learn the boundary of two types of hematoma. When
the HU values of the red squares in the upper left and lower
right corners are both greater than the red square in the middle,
it indicates that the middle is likely to be the boundary area of
the two types of hematomas. Using dilated convolutions with
different dilation rates can learn the trend of the gradual change
of the distance between the two types of hematoma boundaries.
If only a single convolutional kernel of small size is used, the
model can only understand which side is a hematoma and which
side is not. In addition, the purpose of adding a multi-scale
boundary aware module on the top layer of the encoder is to
learn the relative positional relationship of the two types of
hematomas in the whole slice under the condition of the larger
receptive field. We use convolutions with dilation rates of 1, 2,
3, and pointwise convolution for feature extraction, and then
concatenate the output feature maps.
2) Loss Function: In medical image segmentation tasks,
class label imbalance often occurs. Many loss functions have
been designed to alleviate this problem, such as Dice loss [30].
Dice loss solves this problem by comparing the similarity be-
tween the prediction results and the ground truth. We adopt
Dice loss as the loss function for MBA-UNet three-category
prediction.
 consistency loss. CE represents the cross-entropy loss. Softmax
2 |Pout GT |
lossseg = 1 − (1)
|Pout | + |GT | + ξ
where Pout represents the prediction result of the network, GT
represents the ground truth, and ξ represents the smoothing
coefficient.
Furthermore, we also propose a consistency loss function.
In the boundary area of the two types of hematoma, a pixel
can be predicted as two categories at the same time with high
probability. To reduce the occurrence of this situation, we add
the prediction result of IPH, Piph ∈ R1×512×512×8 and the pre-
diction result of IVH, Pivh ∈ R1×512×512×8 pixel by pixel to get
Pall ∈ R1×512×512×8 . Then, we use Dice loss to constrain the
consistency of Pall and Pich .
 We adopt the Dice coefficient (DSC) as the most important
2 |Pall Pich |
lossconsisitency = 1 − (2)
|Pall | + |Pich | + ξ
Therefore, the loss function of the model can be defined as,
loss = lossseg + lossconsistency
C. Data Post-Processing
In the inference phase, segmentation predictions for the case
are obtained by recombining the outputs of the network. Two
adjacent outputs have an overlap of 1/2, in other words, the
stride along the Z axis is 4. For each voxel, we use the highest
probability of all output blocks as its final prediction. After
recombining to get the segmentation prediction of the case, we
use 0.5 as the threshold, set the voxels greater than or equal to
the threshold to 1, and set the voxels less than the threshold to
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0 to obtain the prediction result. In addition, we also employed
SimpleITK [31] to fill the hole inside the hematoma and then
removed the hematoma with a single connected area of fewer
than 1 ml.
IV. RESULTS
A. Experimental Setup
We use the same optimizer and hyperparameter settings for all
models. In addition to the proposed model, we use dice loss as the
loss function for other models. We use the Adam optimizer [32].
We set the learning rate to 0.0001 and the batch size to 16.
The size of the randomly cropped 3D blocks for 3D U-Net is
32 × 256 × 256. The size of randomly sequentially cropped 3D
blocks for 3D U-Net is 8 × 512 × 512. All experiments were
performed on Pytorch 1.7.1 [33]. The hardware environment is
a 4 Tesla V100.
We use random sequential (RS) 3D U-Net [19], random
sequential 3D U-Net with MBAM (RS + MBAM), and random
sequential 3D U-Net with MBAM and consistency loss (pro-
posed) for ablation study. The ablation study results are shown
in Table II. We use U-Net [15], random crop (RC) 3D U-Net [19],
and 3D U-Net RS to study the effect of different input sizes. The
different input sizes results are shown in Table III. We use RS
+ MBAM as a baseline network to study the effect of different
loss functions. BCE represents the binary cross-entropy loss.
DICE represents the dice loss. CON represents the proposed
represents the softmax activation function. Experiments that do
not indicate the activation function use the sigmoid activation
function. The different loss results are shown in Table IV. We use
the 3D U-Net RS with consistency loss as a baseline network to
study the effect of different dilation rates. Dilation 1 represents
that only dilated convolution with a dilation rate of 1 is used.
Dilation 2 represents that dilated convolutions with dilation
rates of 1 and 2 are used. The meaning of Dilation n can be
deduced like this. The different dilation rate results are shown in
Table V.
B. Evaluation Metrics
evaluation metric of the model segmentation result, which is
defined as,

2 |P red GT |
DSC = (4)
(3) |P red| + |GT |
where P red represents the prediction result of the network, GT
represents the ground truth.
In addition, we also employ precision (Prec), sensitivity
(Sens), specificity (Spec), and accuracy (Accu) to evaluate the
segmentation results of the model.
Accurate determination of hematoma volume is important for
clinical surgical guidance. Different volumes of hematoma have
different treatments. Therefore, we calculated the hematoma
volume predicted by the model by (5) and compared it with the
ABC/2 [34] method that is commonly used in clinical practice
TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE 4459

TABLE II
ABLATION STUDY
models

TABLE III
METRICS FOR SEGMENTATION USING DIFFERENT INPUT SIZES

TABLE IV
METRICS FOR SEGMENTATION USING DIFFERENT LOSSES

to measure hematoma volume. Both IPH and IVH have the case in the world space. We obtain the volume represented
possibility of multiple occurrences, so we cannot directly obtain by each pixel by reading the three axial coordinate intervals
the maximum connected area. Here, we calculate the volume of represented by the spacing parameter in the DICOM image and
each hematoma and sum, multiplying these three coordinate intervals.
We use SimpleITK [31] to compute the centroid CP red of the

n
Vi = Pi × S (5) model prediction results and the centroid CGT of the ground
i=1 truth. Then, we calculate the Euclidean distance between CP red
and CGT , as the centroid deviation (CD).
where Pi represents the i-th hematoma predicted by the network, Finally, we give a path planning scheme for minimally
and S represents the volume of each pixel of the corresponding invasive surgery for some cases with IPH. Professional

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4460 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO. 9, SEPTEMBER 2023
TABLE V
METRICS FOR SEGMENTATION USING DIFFERENT DILATION RATES
neurosurgeons judge whether the planned path is reasonable, to
make necessary preliminary preparations for minimally invasive
surgery navigation.
C. Ablation Study
According to the experimental results in Table II, for IPH,
adding MBAM to 3D U-Net (RS), DSC can be improved by
2.84%. Adding consistency loss to MBAM + RS, DSC can
be further improved by 2.30%. For IVH, adding MBAM to
3D U-Net (RS), DSC can be improved by 3.11%. Adding
consistency loss to MBAM + RS, DSC can be further improved
by 5.05%. Since our purpose is to perform path planning for
IPH and IVH according to the amount of hemorrhage and the
location of hemorrhage, we will not analyze the relevant metrics
of ICH in the experimental results in detail. In summary, both our
proposed MBAM and consistency loss can effectively improve
the segmentation efficiency of the model.
D. Comparative of Different Input Sizes
According to the experimental results in Table III, for IPH,
the highest DSC is obtained using the 3D U-Net (RS), which
is 0.8446. For IVH, the highest DSC is obtained using 3D U-
Net (RS), which is 0.6263. Although for IPH, the segmentation
efficiency using U-Net and 3D U-Net (RS) is close. For IVH,
the segmentation efficiency of 3D U-Net (RS) is much better
than that of U-Net. It is beneficial for using consistency loss.
Furthermore, it also shows that both contextual information and
global axial information are necessary for segmenting IPH and
IVH. Therefore, we use random sequential slices as input to the
network.
E. Comparative of Different Losses
According to the experimental results in Table IV, for IPH,
the highest DSC is obtained using DICE + CON. For IVH,
the highest DSC is also obtained using DICE + CON. When
using BCE and its combined loss function, the model has a
poor ability to distinguish between two hematomas and tends
to classify some difficult pixels into two hematomas at the
same time. Therefore, when using BCE and its combination loss
function, high recall can be obtained, but the precision is low.
When using DICE and its combined loss function, the network
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can achieve better segmentation results. Using DICE + CON
can effectively solve the above problems. Although the recall is
slightly reduced, the high precision can obtain a more accurate
centroid position, which is crucial for judging the location of
hematoma and planning of the catheter path.
F. Comparative of Different Dilation Rates
According to the experimental results in Table V, for IPH,
the highest DSC is obtained using Dilation 3. For IVH, the
highest DSC is also obtained using Dilation 3. DSC for both
IPH and IVH decreased when using Dilation 4 compared to
using Dilation 3. Therefore, an excessively large receptive field
may also interfere with the judgment of the model. It may
be because an excessively large receptive field will mislead
the model to associate two disjoint hematomas as connected
hematomas. Combined with the experimental results, we use
Dilation 3 in this study.
G. Centroid Deviation
We excluded cases with maximal connected areas < 5 ml for
IPH and IVH and cases containing multiple connected areas such
as amyloid lesions. Because these cases are usually not treated
with catheter surgery. After the screening, there were 75 cases
of IPH and 47 cases of IVH. It shows the centroid deviation for
segmenting IPH and IVH using different models in Tables VI and
VII. For IPH, the centroid deviation is 5.0193 mm using U-Net,
7.4674 mm using 3D U-Net (RC), 4.8574 mm using 3D U-Net
(RS), 5.0148 mm using RS + MBAM, and 4.3835 mm using the
proposed model. For IVH, the centroid deviation is 16.6122 mm
using U-Net, 41.6892 mm using 3D U-Net (RC), 14.9987 mm
using 3D U-Net (RS), 14.3479 mm using RS + MBAM, and
13.9159 mm using the proposed model. Therefore, the centroid
deviation for two types of hematoma using the proposed model
is minimal, which is beneficial for path planning.
H. Visualization of Experiment Results
We selected the with/without of IVH, the breaking points
at different positions, and the hematomas of different sizes
and shapes for visualization, as shown in Fig. 4. According
to the visualization results of the first, third, fourth, and fifth
slices, due to the lack of contextual information in U-Net,
TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE 4461

Fig. 4. Visualization of segmentation results for different models, where red represents true positives, green represents false positives, and blue
represent false negatives.

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4462 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO. 9, SEPTEMBER 2023

TABLE VI
CENTROID DEVIATION OF IPH WHEN USING DIFFERENT MODELS

TABLE VII
CENTROID DEVIATION OF IVH WHEN USING DIFFERENT MODELS

the hematoma with island sign can easily mislead the model,
resulting in mis-segmentation. According to the visualization
results of the second, third, fourth, and fifth slices, 3D U-Net
(RC) cannot accurately segment IPH and IVH. It is because
IPH and IVH have no significant difference in HU value and
texture characteristics. Therefore, when the global information
is lost due to random cropping, the model cannot accurately
distinguish the relative position information of the two types
of hematomas. The model will tend to classify all hematomas
as IPH. According to the visualization results of the fourth and
fifth slices, 3D U-Net (RS) can obtain contextual information
and global information at the same time. However, it is not ideal
when the hematoma is irregular in shape or the breaking point is
large. The boundaries of the two types of hematomas in 3D space
are gradually separated, from intertwined near the breaking point
to two independent boundaries. Therefore, RS + MBAM can
obtain better results according to the visualization results of
the fourth slice. According to the visualization results of the
fifth slice, adding the consistency loss can further improve the
segmentation efficiency of the model, and a better segmentation
effect can be obtained at the boundary between the two types of
hematomas.
In addition, we also selected some difficult cases encountered
in practical applications for visualization, as shown in Fig. 5.
Difficult cases refer to IPH closely connected with IVH, the
boundaries of the two hematomas are very blurred, and more
information in adjacent slices must be combined for segmenta-
tion. It is also difficult for senior neurosurgeons to distinguish the
boundary between these two hematomas. Our current research
Fig. 5. Visualization of segmentation results for difficult cases.
mainly focuses on planning the puncture path of IPH. Therefore,
we focus on the segmentation results of IPH. The visualization
results of each slice are divided into two rows. The first row is
five consecutive slices with the middle slice as the segmentation V. DISCUSSIONS
target, and the second row is the segmentation results of five
models. The red dotted box is the area where IPH and IVH A. The Effect of Distinguishing IPH From ICH to
are entangled. From these segmentation results, although the Centroid Prediction
proposed method has mis-segmented regions, the segmentation We selected cases with IPH broken into ventricular which are
efficiency is higher and more stable than the comparison method. described in Section IV-G, and calculated the centroid deviation

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TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE
TABLE VIII
THE CENTROID DEVIATION OF IPH AND ICH WHEN USING THE PROPOSED MODEL
Fig. 6. Performance comparison of model and neurosurgeon. DL/Inter
represents the model and the intermediate doctors, DL/Senior repre-
sents the model and the senior doctors, and Inter/Senior represents the
intermediate doctors and the senior doctors.
of IPH, ICH, and IPH from ICH in these cases, as shown
in Table VIII. The suffix P represents the prediction result,
and the suffix GT represents the ground truth. We can obtain
that for cases with secondary IVH, the centroid deviations of
ICH and IPH is small from Table VIII. Meanwhile, for the
removal of IVH, although catheter on either side can clear the
ventricles with equal efficiency [35], if the IPH and IVH are
not separated, the result of direct puncture using the centroid
of the ICH is likely to be not ideal. The centroid of the IPH-P
differs significantly from the centroid of the ICH-GT, with an
average deviation of more than 19 mm. It is likely to adversely
affect the catheter. The average deviation of the centroid of the
IPH-P from the centroid of the IPH-GT is 5.6581 mm, and more
than 85% of the cases had centroid deviations less than 10 mm.
It is beneficial for catheter planning. Although a deviation of
10 mm may be acceptable, there are still 15% of cases where
the deviation exceeds 10 mm. These cases with large deviation
may bring potential risks to patients. Therefore, we recommend
that clinicians need to confirm the segmentation results of the
model before performing EVD.
B. Performance Comparison of Model Segmentation
Results and Clinician Manual Labeling
We selected the cases which are marked with disagreement
by two intermediate doctors in the test set, for a total of 24
cases. At this time, the senior doctor will revise it based on the
results marked by the two intermediate doctors. We compared
the correlation of the proposed model segmentation results, the
labeling results of intermediate doctors, and the labeling results
of senior doctors, as shown in Fig. 6. For IPH, the DSC of model
and intermediate doctors is 0.8950, and the DSC of model and
senior doctors is 0.8922, and the DSC of intermediate doctors
and senior doctors is 0.9551. For IVH, the DSC of model and
intermediate doctors is 0.7046, the DSC of model and senior doc-
tors is 0.7577, and the DSC of intermediate doctors and senior
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4463
Fig. 7. Performance comparison of the proposed model and clinical
methods for measuring hematoma volume. DL indicates the proposed
model, ABC/2 indicates the clinical method and GT indicates the ground
truth.
doctors is 0.8926. Although the DSC of model and senior doctors
is 0.1349 lower than that of intermediate doctors and senior
doctors in terms of IVH, the DSC of model and senior doctors is
only 0.0629 lower than that of intermediate doctors and senior
doctors in terms of IPH and reached 0.8922. Therefore, for IPH,
the proposed model can obtain good segmentation results, and
preliminary labeling of hematomas can be performed in clinical
practice, which greatly reduces the workload of doctors.
C. Comparison of Model Segmentation and Clinical
Measurement of Hematoma Volume
We used the same data as in Section IV-G. We used the ABC/2
method and the proposed model to count the hematoma volume
in each case, as shown in Fig. 7. For IPH, the Pearson correlation
of the ABC/2 method with the ground truth is 0.9219, p <
0.0001. The Pearson correlation of the proposed model with
the ground truth is 0.9887, p < 0.0001. Moreover, the accuracy
of prediction using the proposed model is significantly higher
than the ABC/2 method employed in clinical practice. For IVH,
the Pearson correlation between the ABC/2 method and the
ground truth is 0.8302, p < 0.0001. The Pearson correlation
of the proposed model with the ground truth is 0.9055, p <
0.0001. The accuracy of using the proposed model is similar
to the ABC/2 method used in clinical practice. Therefore, in
summary, the hematoma volume predicted by the proposed
model is superior to the clinical measurement method and has
no significant difference from the ground truth, which has the
potential for clinical application. In addition, we also use the
Bland-Altman method to evaluate the volume of IPH and IVH
to help clinicians more intuitively and quickly identify cases
with large deviations in Fig. 8. For IPH, although there are a few
outliers, the overall consistency is better. For IVH, all results are
within confidence intervals. For IPH and IVH, the segmentation
was better when the hematoma volume was larger.
4464 IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 27, NO. 9, SEPTEMBER 2023
Fig. 8. Bland-Altman analysis of hematoma volume.
Fig. 9. Correlation of DSC with centroid deviation.
D. Correlation Between Model Segmentation
Performance and Centroid Deviation
We used the same data as in Section IV-G. We calculated the
correlation of DSC with centroid deviation, as shown in Fig. 9.
Combined with the results in Table VI, for IPH, the centroid
deviation of 8% of the cases exceeds 10 mm, and the maximum
centroid error is 44.87 mm. The Pearson correlation between
DSC and centroid deviation was -0.8553, p < 0.0001. Combined
with the results in Table VII, for IVH, the centroid deviation
exceeded 20 mm in 14.67% of the cases, with a maximum
centroid deviation of 42.30 mm. The Pearson correlation of DSC
with centroid deviation was −0.8276, p < 0.0001. Combining
the results in Tables II, III, VI, VII, and Fig. 9, it can be seen
that the range of centroid deviation is approximately negatively
correlated with DSC, that is, the larger the DSC, the smaller
the centroid deviation. Small centroid deviation is an important
prerequisite for catheter path planning. In conclusion, a high
DSC is important for the planning of puncture paths.
E. Correlation Between Model Segmentation
Performance and Path Planning
Fast and accurate segmentation of IPH and IVH is an im-
portant prerequisite for EVD. First, we can judge the type of
hematoma based on the segmentation results. If it is multiple
hematoma such as subarachnoid hemorrhage, it is often not
suitable for EVD. Then, judge whether EVD is needed according
to the volume of hematoma. If the volume of hematoma is
small, EVD may not be performed. Secondly, different puncture
strategies need to be adopted according to different hematoma
locations (such as supratentorial, infratentorial, and brainstem,
etc.). If it is determined to perform EVD, we need to plan
the puncture plan based on the hematoma centroid obtained
by segmentation. The volume, location, shape, and centroid of
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Fig. 10. Visualization of the planned path for catheter surgery in two
cases with IPH.
the hematoma are closely related to the segmentation perfor-
mance of the hematoma. Therefore, accurate segmentation of
the hematoma is an important prerequisite for surgical planning.
Based on the centroid obtained from the proposed model, we
performed path planning for the cases with IPH that met the
conditions for catheterization. Since the proposed model does
not meet the conditions for clinical application in the prediction
of IVH-related parameters. Therefore, we visualized the catheter
planning path for 2 cases with IPH in Fig. 10. The first case is
a thalamic hemorrhage, the hematoma volume is 33.52 ml, the
DSC is 0.9646, the length of the path inside the hematoma is
8 mm, the length of the path outside the hematoma is 32.2 mm,
the coordinates of the puncture point are [89, 162, 185], and the
coordinates of the target point are [86, 162, 145] with an angle
of 5.37. The second case is cortical hemorrhage, the hematoma
volume is 82.18 ml, the DSC is 0.8612, the length of the path
inside the hematoma is 18.1 mm, the length of the path outside
the hematoma is 7.1 mm, the coordinates of the puncture point
are [95, 197, 74], and the coordinates of the target point are
[98, 188, 96], the angle is 37.54. The evaluation criteria for path
planning need to be judged by clinicians in combination with
medical guidelines. Clinicians judge whether the puncture path
planning is successful based on a series of evaluation factors. It
was confirmed by the clinician that the catheter path planning
of the above two cases met the clinical requirements. According
to our statistics, when CD < 10 mm or DSC > 0.8, the rate of
path planning meeting the requirements is 100%. When using
the data in Section IV-G, only 6 cases did not meet the above
criteria, that is only 8%. However, in only 3 of the 6 cases,
the planned route did not meet the requirements. Therefore,
the proposed model achieves 96% accuracy for catheter path
planning.
F. Future Works strenth
In terms of IPH, the proposed model can obtain accurate
hematoma-related parameters, which greatly reduces the work-
load of clinicians and has the prospect of practical application.
However, in terms of IVH, the proposed model cannot obtain
TONG et al.: DEEP LEARNING MODEL FOR AUTOMATIC SEGMENTATION OF INTRAPARENCHYMAL AND INTRAVENTRICULAR HEMORRHAGE
limitation/future work
sufficiently accurate hematoma-related parameters, which is a
problem that needs to be solved in the future. The model cannot
accurately identify the borders of the two types of hematoma
when the breaking point is large and the borders of the two types
of hematomas are mixed. Therefore, how accurately segment
difficult cases is also an urgent problem to be solved.
VI. CONCLUSION
We developed a deep learning model for the automatic seg-
mentation of intraparenchymal and intraventricular hemorrhage
for clinical catheter puncture path planning. The proposed model
can obtain more accurate segmentation results compared with
other deep learning methods. Experiments show that our pro-
posed method has the potential for clinical application, and can
provide clinicians with more abundant reference and guidance
information.
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