A Gated Attention-Based Multiple Instance Learning and Test-Time Augmentation Approach for Diagnosing Active Sacroiliitis in Sacroiliac Joint MRI Scans

Background and Objective: Axial spondyloarthritis (axSpA) is a group of chronic inflammatory diseases that primarily affect the sacroiliac joints. Early diagnosis is crucial for preventing irreversible structural damage. Magnetic Resonance Imaging (MRI) is the gold standard for detecting early inflammatory changes such as sacroiliitis. However, conventional MRI interpretation is inherently subjective and susceptible to both intra- and inter-observer variability. Therefore, artificial intelligence (AI)-driven diagnostic solutions are increasingly being explored. Among them, the Gated Attention Multiple Instance Learning (MIL) framework holds strong potential in modeling heterogeneous inflammatory distributions, thanks to its slice-level attention mechanism. This study aims to evaluate the diagnostic performance of a deep learning model based on Gated Attention MIL for automated sacroiliitis detection. Furthermore, its results are compared with a baseline deep learning architecture (standard ResNet-18), and its consistency with radiologist annotations is analyzed. Materials and Methods: The dataset included 554 subjects, comprising 276 patients diagnosed with axSpA and 278 healthy controls. All MRI data were derived from axial T2-weighted fat-suppressed (T2_TSE_TRA_FS) sequences. Patient-wise data splitting was employed to construct training, validation, and independent test sets. The proposed model architecture integrates ResNet-18-based feature extraction, a gated attention mechanism for instance-level weighting, and bag-level classification. Additionally, Test-Time Augmentation (TTA) was implemented to enhance robustness during inference. Results: On the independent test set, the model achieved an accuracy of 85.88%, sensitivity of 92.86%, specificity of 79.07%, and an F1-score of 86.67%. Attention heatmaps generated by the MIL module showed strong spatial overlap with bone marrow edema regions annotated by expert radiologists. Implementation of TTA led to an approximate 10% improvement in overall classification accuracy. Conclusions: The Gated Attention MIL framework demonstrated high diagnostic performance for sacroiliitis detection, indicating its value as a reliable decision support tool for early axSpA diagnosis. Validation on larger, multi-center datasets is warranted to ensure generalizability and to support clinical integration in routine radiology workflows.