The 7th IEEE International Conference on E-Health and Bioengineering - EHB 2019

Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, November 21-23, 2019

Choosing Between Artificial Neural Networks and

Bayesian Inference in Stroke Risk Prediction
Adriana Albu1, Loredana Stanciu1, Mădălina-Sofia Pașca2,3, Cristian-Grigore Zimbru1
1 Automation and Applied Informatics Department, Politehnica University Timisoara, Timisoara, Romania,
adriana.albu@aut.upt.ro, loredana.stanciu@aut.upt.ro, cristian.zimbru@aut.upt.ro
2 Mathematics Department, Politehnica University Timisoara, Romania, madalina.pasca@upt.ro
3 West University Timisoara, Romania, madalina.pasca79@e-uvt.ro

Abstract — Artificial intelligence (AI) provides a multitude of
mechanisms that can be used to implement medical predictions
systems. Even if this subject has been intensively debated during
the last decades, choosing the most suitable mechanism is still a
challenge. The research described in this paper focuses on stroke
risk prediction and offers a tool meant to assist physicians in their
decisions. Two consecrated methods are implemented (artificial
neural networks and naive Bayesian classifier), and a comparison
between them is provided. The results show that these methods
have similar performances and can offer a valuable support for
medical predictions.
Keywords — artificial intelligence, artificial neural networks,
Bayesian classifier, stroke.
I. INTRODUCTION
Stroke is a serious cause for long-term disability or death.
For this reason, the development of automated tools that can pro-
vide predictions regarding vascular events is fully justified. The
aim of these tools is to support physicians, by detecting or pre-
dicting a medical condition. This way, a serious disease can be
efficiently treated or even avoided.
There are several risk factors connected to stroke, but it is
difficult to determine what influence they have on vascular dis-
eases. An automated system that is using AI techniques could be
able to identify high-risk patients. The present paper describes
such a system that, analyzing the features of a patient, is able to
make predictions regarding the risk of a stroke, including the pa-
tient in one of the four risk categories.
The aim of this research is to validate some previous results
published by the same authors in [1]. The main idea is to provide
arguments for choosing between Artificial Neural Networks
(ANN) and Naive Bayesian Classifier (NBC) when a medical
prediction system is developed. The system described in [1] was
implemented to make suggestions regarding the evolution of pa-
tients infected with Hepatitis B virus. The research presented in
the current paper focuses on the stroke risk predictions and im-
plements the same mechanisms (NBC and ANNs), trying to
draw some conclusions regarding the most suitable method for
this type of applications.
The comparison between these two classifiers is still a chal-
lenge for researchers. This aspect is emphasized in the second
section of this paper. The research described by the current paper
starts from an application previously developed for cerebrovas-
cular accident (also called stroke) risk prediction [2]. This appli-
cation was initially implemented using ANNs only. In the cur-
rent work it is implemented again, in an optimized manner and
it is briefly described in the third section of this paper. The same
issue is solved using NBC and the solution is presented in the
fourth section. Details about the dataset that has been used are
provided in the section five. The sixth section underlines the re-
sults, while the seventh one draws the conclusions.
II. RELATED WORK
There are numerous papers that analyze the performances of
ANNs and NBC, either used in parallel, for the same purpose, or
combined into a single entity, which makes use of the ad-
vantages provided by both methods. It is worth to mention sev-
eral results, even if some of these papers have been written more
than twenty years ago. Actually, this demonstrates a long-stand-
ing concern for this subject.
As stated in [1], the comparison between ANNs and NBC
has been debated for a long time. For example, in [3], the authors
obtained similar performances for these two classifiers. Another
study ([4]) showed that ANN is a better identifier, but NBC was
not far away. In the experiment presented in [5] naive Bayesian
classifier outperforms ANNs model. The comparison made in
[6] demonstrated that NBC is the best choice (against the deci-
sion trees and neural networks) for that particular task. More re-
cently, the researchers concluded in [7] that ANNs had excellent
results, while NBC requires further investigations.
There are researchers that have used these two classifiers to-
gether. For instance, in [8], the posterior probabilities provided
by NBC model are trained with an ANN for the final prediction.
Brest cancer is detected in [9] using Bayes algorithm for proba-
bility of identification and neural networks for classification.
Another example is provided by [10], where an ANN is used for
predictions and a discrete Bayes network for interpretation.
Stroke is also a subject of interest for expert systems meant
to assist medical decision-making. An elaborated analysis is pro-
vided in [11], where ANNs and logistic regression models are
developed to predict the mortality after stroke. The authors
prove that the ANNs model is superior.

978-1-7281-2603-6/19/$31.00 ©2019 IEEE

 Therefore, in the last several decades, the tools based on AI
methods have become more and more popular for the research-
ers who are involved in the medical field. Nevertheless, it looks
that there is still enough room for further developments and
opinions.
III. ARTIFICIAL NEURAL NETWORKS
The work in Machine Learning domain started several dec-
ades ago with ANNs. Nowadays, these are still among the most
popular and efficient forms of learning systems [12], classifica-
tions using conventional neural networks being able to produce
adequate detections and predictions.
An ANN is a model that reproduce, in a simplified way, the
architecture of the human brain. It is made by artificial neurons
which, using different activation functions, try to simulate the
chemical behavior of living creatures' neurons. ANNs acquire,
store and use knowledge, developing the ability to make deci-
sions by learning from ordinary experience, as humans do [13].
Using the processing power of modern technology, they are able
to execute parallel distributed computations, to tolerate noisy in-
puts, to learn new associations, new patterns and new functional
dependencies [12, 13]. All these features make them suitable for
applications meant to support medical decision-making [1].
In this work, ANNs have been used to classify a patient in
one of the four possible risk categories of stroke. A function fit-
ting neural network (a specialized version of feedforward net-
work), with one hidden layer has been created and trained.
There are 11 features that are analyzed for a patient with
vascular problems. The ANN is using these features as inputs.
Then follows the hidden layer of the network. The number
of neurons from this layer is usually empirically established, be-
cause, as stated in [13], the decision regarding this number
doesn’t have a conclusive solution appropriate for any task. The
current application has 10 neurons on this layer.
The result is produced by the output layer, which contains a
single neuron. It generates a number, representing the risk cate-
gory: 1 indicates the lowest risk of stroke and 4 the highest one.
Each neuron of the network is firing according to an activa-
tion function, which internally analyzes the weighted inputs. The
hyperbolic tangent sigmoid activation function has been used for
the neurons that belong to the hidden layer, while the output neu-
ron has a linear activation function.
There are several algorithms that can be used for the training
process. According to the environment’s documentation, the Le-
venberg-Marquardt backpropagation algorithm is the most suit-
able for this type of problems, being also the fastest.
The initial values of the inputs' weights of each neuron influ-
ences the performance of the ANN. But there is no rule that spec-
ifies which should be the proper values. For this reason, the cur-
rent system created and trained 1000 ANNs. The most accurate
of them has been saved and further used to make predictions.
IV. BAYESIAN INFERENCE
Statistics remains the best tool for analyzing data and for as-
sisting decision-making activity [1]. In this field, one of the most
popular methods is Bayes’ theorem – a formula with conditional
probabilities, which implements probabilistic reasoning [14] and
which can be successfully used to make predictions. When ap-
plied in medical diagnosis, its general form [12] can be written
as in (1), where Dk is the cause (the possible diagnosis, this case,
the possible risk category of stroke) and S is the effect (the symp-
toms or the features of a patient).
( )⋅∏ ( | )
( | )= (1)
∑ ( )⋅∏ ( | )
The value m from (1) represents the number of risk catego-
ries, n is the number of features, and σi is a feature. This formula
determines, for a patient characterized by a set of features S, the
probability of each one of the four stroke risks Dk (therefore, k =
1…4). The elements from (1) can be calculated using equations
(2), (3), and (4):
( )= (2)
Ω
( , )
( | )= (3)
( )
∩
( , )= (4)
Ω
where Ω represents the number of records from the database.
Therefore, p(Dk) is the ratio between the number of patients that
have the risk Dk and the total number of patients, and p(σi, Dk)
is the number of patients that simultaneously have the risk Dk
and the feature σi, divided by the total number of patients.
Bayes’ theorem assumes some constraints [1] that have to be
analyzed each time it is used into a system like this:
⎯ the risk categories have to be mutually exclusive (only one
for each patient) – it is obvious that a patient cannot belong
to more than one risk category at a moment;
⎯ the features have to be conditional independent, given a risk
category Dk – this constraint is not always satisfied (for in-
stance, it is difficult to demonstrate that cholesterol do not
influence EKG), but, according to relevant researchers [12],
NBC works proper and offers surprisingly good results,
even with inputs that are not conditional independent.
V. DATASET
The quality of the results provided by a classification model
is strongly connected to the database that is analyzed. Both al-
gorithms implemented within this system are using the same
data. There are 108 records containing anonymized information
about patients with vascular problems. All this data has been col-
lected from Municipal Clinical Emergency Hospital of
Timisoara, during 2015-2016 [2].
The datasets used in statistics and machine learning should
accomplish some requirements in order to avoid two types of
limitations. On the one hand, the system could be unable to
learn, having poor predictive performance, if there are very few
records available. On the other hand, too many features, some of
them irrelevant, can lead to overfitting, the system being unable
to generalize, because it learns exactly the characteristics of a
particular set of data.
Therefore, the design and the content of the database are sig-
nificant elements that increase the performances of a medical
prediction system. Table I presents the features that have been
 TABLE I. PATIENT'S FEATURES VI. RESULTS AND DISCUSSION
range [9 - 91] The prediction system has a graphical user interface (Fig. 1)
Age (years) that includes, in the same window, both implemented methods.
mean 47.08
male 57 This way, their results can be compared easier. In the left side of
Gender
female 51 the interface the user introduces the features of a new patient (or
Dyslipidemia range [70 - 169] uploads them from an external file). The other two panels of the
(high cholesterol) mean 112.77 interface are dedicated to NBC and ANN.
range [50 - 153]
Abdominal Circumference
mean 91.79 Both methods provide predictions regarding each risk cate-
HLV on Echocardiogram range [57 - 155] gory when the button "Calculate" is pressed. The accuracy is
(Hypertrophic Left Ventricle) mean 101.69 also displayed if the button "Test" is used. As can be observed
HLV EKG Sokolov-Lyon range [2 - 66] in Fig. 1, for the considered dataset, both methods have the same
(Hypertrophic Left Ventricle) mean 33.92
accuracy: 88.89%.
GFR (Glomerular Filtration range [12 - 60]
Rate) mean 35.15 The Bayesian inference offers as results probabilities. There-
LV (Left Ventricle) Wall range [0.1 - 1.3] fore, each risk category has associated a number in the range
Thickness mean 0.64
[0...1]. The sum of the probabilities of the four risk categories
range [115 - 334]
Postprandial Glycaemia
mean 197.22 should be 1.
range [70 - 194] The ANN provides a definite classification. A single risk cat-
A Jeun Glycaemia
mean 117.46
egory will have the value 1, the rest of them being 0. An addi-
none 47
angina 29
tional button (Train) is available in this panel, but not for regular
myocardial infarction users; the network has already been trained.
Previous Condition 20
(heart attack)
coronary revasculari-
A probability is a valuable information, because this way, the
zation
12 human expert who is using the system can evaluate the medical
1 - the lowest risk 40 status of the patient. For instance, it could be a relevant differ-
2 27 ence, from a medical point of view, between a risk prediction of
Risk
3 16 0.95 and one of 0.55 provided by the NBC. The ANN will say,
4 - the highest risk 25 in both cases, that the prediction is 1.
considered, together with some statistical elements (range of Regarding the performances of this system, there are several
their values, mean, number of records with a particular value). metrics that can be used to evaluate it. The graphical interface
The risk of stroke (which is the ground truth regarding the pre- displays the accuracy only, but few others are available. Even if
diction) is also stored into the database. the accuracy is the most popular evaluation method, it is not al-
ways the best one. A model can be highly accurate in testing
All these features are used by both classification algorithms.
phase, especially if the dataset has a dominant category (it is not
ANN takes them as they are. NBC needs them processed, be-
the case of this dataset, where the risk categories are well-bal-
cause it requires binary data; therefore, some of these fields have
anced, as can be seen at the end of Table I). But, when the model
been split in two, three, and even four ranges.
is used for real predictions, it could provide incorrect results for
The dataset has been divided in two parts, required for such particular cases. This is the so-called accuracy paradox, and for
a system. From the 108 available records, 81 have been used for this reason some other metrics should be used in parallel to eval-
training and 27 have been reserved for testing. uate the performances of a predictive system.

Fig. 1 Graphical user interface

 In order to calculate these classification metrics, the confu-
sion matrix was created. It contains information about the pre-
dicted risk, with respect to the ground truth value. The definition
of the confusion matrix and the values resulted in the testing
phase for each classifier are presented in Table II.
This system provides a result (the risk category) that belongs
to one of the four possible classes (unlike a regular classification,
which consists in two classes: positive and negative). Therefore,
the meaning of the elements that compose the confusion matrix,
for this particular case, is the following:
⎯ TP – true positive: the prediction is correct;
⎯ TN – true negative: doesn't exist; this system will never say
that there is no risk (risk = 0 is an impossible output);
⎯ FP – false positive: the prediction is greater than the real
value;
⎯ FN – false negative: the prediction is less than the real value.
Using these elements, the classification metrics sensitivity
and precision can be found. Their description and the obtained
values are provided in Table III.
There are two other metrics, specificity and negative predic-
tion value, but these cannot be evaluated because the system
doesn't provide true negative results. Instead, the F1 score (har-
monic mean between recall and precision: 2 x Precision x Recall
/ (Precision + Recall)) can be calculated. The resulted value is
0.94 for each method, which demonstrate a sort of balance be-
tween precision and sensitivity.
VII. CONCLUSIONS
This research aimed to compare two AI models, NBC and
ANN, in order to consolidate some previous results and to
choose the most suitable one for stroke risk prediction. A defi-
nite conclusion cannot be drawn, the two models having similar
performances. NBC doesn't provide any FP value, while ANN
doesn't have any FN value. ANN is better than NBC regarding
the sensitivity of the model, but NBC outperforms ANN in pre-
cision.
The modest number of records that are available is an im-
pediment. Both statistics and machine learning need a relevant
dataset in order to model the desired behavior.
There are some ideas that can be further implemented. For
instance, an intensive training could be performed (if much more
records would be available) and the performance metrics could
be evaluated with respect to each category, not to the entire pro-
TABLE II. CONFUSION MATRIX
Method
Definition NBC ANN
(predicted class)
Real TP FN 24 3 24 0 Belgica, 112(4), 2012, pp. 375-382
(actual class) FP TN 0 0 3 0
TABLE III. EVALUATION METRICS
Value for Value for
Name Formula
NBC ANN
Sensitivity (recall) TP/(TP+FN) 0.89 1
Precision (correctness in
TP/(TP+FP) 1 0.89
positive prediction)
cess. This technique would increase the quality of the predic-
tions for real cases. Another idea [11] is to offer predictions not
only for a close moment, but also about what will be the medical
status of the patient after a larger interval of time.
Therefore, there are still many relevant things to do in this
field. The general purpose of this type of models is to provide
tools that are valuable aid for physicians. It is important to say
that all these are certainly not meant to replace human experts,
but to assist them with a second opinion.
ACKNOWLEDGMENT
This work was supported by the CNFIS-FDI-2019-0696 pro-
ject of the Politehnica University Timisoara, Romania.
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