Interpretable machine learning for postoperative sepsis prediction in ICU patients following intracranial hematoma evacuation.

Background: Sepsis is a prevalent and life-threatening complication in ICU patients after intracranial hematoma evacuation. This study aimed to develop and externally validate an interpretable machine learning model for predicting sepsis risk in this high-risk neurocritical care population. Methods: A multicenter retrospective study was designed. The MIMIC-IV was based on for model development and internal testing; MIMIC-III, eICU and an independent clinical cohort from Jiangsu Provincial Hospital of Integrated Traditional Chinese and Western Medicine for external validation. Sepsis during ICU stay was defined according to the operationalized Sepsis-3 criteria. Early ICU variables were selected using Boruta and LASSO, and six machine learning algorithms were developed and compared. Model performance was evaluated by discrimination, calibration, and decision curve analysis, and its interpretability was assessed using SHAP and LIME. A sensitivity analysis was conducted by retraining all six models after excluding baseline SOFA. Results: A total of 1,729 patients were included, of whom 717 developed sepsis during ICU stay. The final model retained 13 predictors, including WBC, SOFA score, SpO Conclusion: This study developed and externally validated an interpretable XGBoost-based model for predicting sepsis risk during ICU stay among patients after intracranial hematoma evacuation. The model showed generally consistent AUC-based discrimination across multiple validation cohorts and may support individualized risk stratification. Further prospective validation and clinical impact assessment are required before routine clinical implementation.