Assessing MRI-based Artificial Intelligence Models for Preoperative Prediction of Microvascular Invasion in Hepatocellular Carcinoma: A Systematic Review and Meta-analysis.

Purpose: To evaluate the performance of magnetic resonance imaging (MRI)-based artificial intelligence (AI) in the preoperative prediction of microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC).

Methods: A systematic search of PubMed, Embase, and Web of Science was conducted up to May 2025, following PRISMA guidelines. Studies using MRI-based AI models with histopathologically confirmed MVI were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Statistical synthesis used bivariate random-effects models.

Results: Twenty-nine studies were included, totaling 2838 internal and 1161 external validation cases. Pooled internal validation showed a sensitivity of 0.81 (95% CI: 0.76-0.85), specificity of 0.82 (95% CI: 0.78-0.85), diagnostic odds ratio (DOR) of 19.33 (95% CI: 13.15-28.42), and area under the curve (AUC) of 0.88 (95% CI: 0.85-0.91). External validation yielded a comparable AUC of 0.85. Traditional machine learning methods achieved higher sensitivity than deep learning approaches in both internal and external validation cohorts (both P < 0.05). Studies incorporating both radiomics and clinical features demonstrated superior sensitivity and specificity compared to radiomics-only models (P < 0.01).

Conclusions: MRI-based AI demonstrates high performance for preoperative prediction of MVI in HCC, particularly for MRI-based models that combine multimodal imaging and clinical variables. However, substantial heterogeneity and low GRADE levels may affect the strength of the evidence, highlighting the need for methodological standardization and multicenter prospective validation to ensure clinical applicability.