Objectives <p>To evaluate the diagnostic performance of four-dimensional flow MRI alone and in combination with spleen volume and splenic extracellular volume fraction (ECV) for identifying high-risk esophageal variceal (HRV) in patients with liver cirrhosis.</p> Materials and methods <p>A total of 58 cirrhosis patients who underwent four-dimensional flow MRI and endoscopy were prospectively recruited and were divided into HRV group (<i>n</i> = 25) and non-HRV (NHRV) group (<i>n</i> = 33). The hemodynamic parameters of the portal vein (PV), superior mesenteric vein (SMV), and splenic vein (SV) derived from four-dimensional flow MRI for identifying HRV were analyzed and compared with spleen volume and splenic ECV. Then a combined model for identifying HRV was constructed by using the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analysis with stepwise forward.</p> Results <p>The peak velocity and maximum pressure gradient of the PV, SMV, and SV, as well as the total volume of the SMV, were significantly greater in the HRV group than in the NHRV group. The SV peak velocity had the highest AUROC for identifying HRV and was comparable to the spleen volume and splenic ECV. The combined model incorporating these three indicators showed superior performance with an AUC of 0.945, outperforming individual imaging indicators and other laboratory-based models.</p> Conclusion <p>Four-dimensional flow MRI is a valuable noninvasive technique for detecting HRV in cirrhosis patients. The combined model incorporating SV peak velocity, spleen volume, and splenic ECV provided an accurate prediction of HRV, which may help avoid unnecessary screening endoscopy.</p> Critical relevance statement <p>The combined model incorporating spleen vein peak velocity derived by 4D flow MRI, spleen volume, and spleen ECV performed better than individual imaging indicators and laboratory-based models, which may help to avoid unnecessary screening endoscopy and aid in clinical decision-making.</p> Key Points <p><UnorderedList Mark="Bullet"> <ItemContent> <p>Noninvasive assessment of the risk of HRV in cirrhosis remains crucial but inadequate.</p> </ItemContent> <ItemContent> <p>Four-dimensional flow MRI can effectively identify HRV in patients with cirrhosis.</p> </ItemContent> <ItemContent> <p>Combining SV peak velocity, splenic volume, and ECV effectively identifies HRV.</p> </ItemContent> </UnorderedList></p> Graphical Abstract <p></p>