Simultaneous Real-time Imaging of Neurofluid and Neurovascular Dynamics Using Ultrafast Flow-weighted Echo-Planar Imaging

Cerebrospinal fluid (CSF) circulation is tightly coupled to cerebral blood flow under the fixed-volume constraint of the cranial vault, with cardiac pulsations and respiration acting as dominant physiological drivers. Disruption of these flow dynamics has been implicated in various neurological disorders, motivating the need for imaging methods that capture CSF and vascular flow simultaneously and in real time. Conventional phase contrast MRI (PC-MRI) provides quantitative CSF velocity measurements but relies on cardiac gating and velocity encoding, which limit temporal resolution, dynamic range, and sensitivity to non-cardiac fluctuations. Here, we introduce self-gated ultrafast real-time flow-weighted echo-planar imaging (SURF-EPI), an inflow-weighted approach in which signal intensity reflects the replacement of saturated spins by freshly inflowing, unsaturated water molecules, yielding higher signal with higher flow. This allows simultaneous assessment of arterial inflow, venous outflow, and CSF motion at high temporal resolution. SURF-EPI was acquired at the C2-C3 spinal level, enabling real-time imaging of CSF flow dynamics in the cervical spinal canal alongside arterial and venous blood flow in major cervical vessels (frame-rate: 21.7 Hz). In addition to frequency-domain analyses, we leveraged intrinsic arterial signal fluctuations as a timing reference to reconstruct cardiac-resolved CSF dynamics for individual cardiac cycles without external physiological recordings. Frequency-domain analysis revealed distinct spectral signatures in CSF flow compared with neurovascular flow, including broadened cardiac peaks and enhanced respiratory modulation, particularly within the ventral spinal canal. In contrast, dorsal CSF showed increased power within the cardiac frequency band, higher coherence with cervical vasculature at the cardiac frequency, and reduced non-cardiac contributions. Time-domain analysis showed strong correlation between CSF flow waveforms derived from SURF-EPI and PC-MRI. Beyond ensemble-averaged waveforms, SURF-EPI enabled beat-to-beat analysis, revealing substantial cycle-to-cycle variability in CSF flow that is not captured by time-averaged gated approaches. Together, these findings establish SURF-EPI as a rapid, complementary framework to PC-MRI, enabling real-time neurofluid imaging with integrated time- and frequency-domain characterization of CSF and neurovascular flow dynamics.