AI-Augmented Quantitative MRI Predicts Spontaneous Intracranial Hypotension.

Background/Objectives: Spontaneous intracranial hypotension (SIH), caused by spinal cerebrospinal fluid (CSF) leakage, commonly presents with orthostatic headache and CSF hypovolemia. While CSF dynamics in the cerebral aqueduct are well studied, alterations in spinal CSF flow remain less defined. We aimed to quantitatively assess spinal CSF flow at C2 using phase-contrast (PC) MRI enhanced by artificial intelligence (AI) and to evaluate its utility for diagnosing SIH and predicting responses to epidural blood patch (EBP). Methods: We enrolled 31 patients with MRI-confirmed SIH and 26 age- and sex-matched healthy volunteers (HVs). All participants underwent ECG-gated cine PC-MRI at the C2 level and whole-spine MR myelography. AI-based segmentation using YOLOv4 and a pulsatility-based algorithm was used to extract quantitative CSF flow metrics. Between-group comparisons were analyzed using Mann-Whitney U tests, and receiver operating characteristic (ROC) analysis was used to evaluate diagnostic and predictive performance. Results: Compared to HVs, SIH patients showed significantly reduced CSF flow parameters across all metrics, including upward/downward mean flow, peak flow, total flow per cycle, and absolute stroke volume (all p < 0.001). ROC analysis revealed excellent diagnostic accuracy for multiple parameters, particularly downward peak flow (AUC = 0.844) and summation of peak flow (AUC = 0.841). Importantly, baseline CSF flow metrics significantly distinguished patients who required one versus multiple epidural blood patches (EBPs) (all p < 0.001). ROC analysis demonstrated that several parameters achieved near-perfect to perfect accuracy in predicting EBP success, with AUCs up to 1.0 and 100% sensitivity/specificity. Conclusions: AI-enhanced PC-MRI enables the robust, quantitative evaluation of spinal CSF dynamics in SIH. These flow metrics not only differentiate SIH patients from healthy individuals but also predict response to EBP treatment with high accuracy. Quantitative CSF flow analysis may support both diagnosis and personalized treatment planning in SIH.