Modality Contribution Score - A Per-Patient Framework for Quantifying the Relative Diagnostic Contribution of Structural MRI and Amyloid PET in Alzheimer's Disease

Multimodal neuroimaging combining structural MRI and positron emission tomography (PET) captures complementary structure-function relationships across the Alzheimer's disease (AD) continuum, yet existing artificial intelligence systems produce a single diagnostic label without quantifying which imaging modality drove that decision for a specific patient. We introduce the Modality Contribution Network (MCNet) and the Modality Contribution Score (MCS), the first per-patient attribution framework quantifying the shift in modality dominance from structural atrophy to amyloid and metabolic dysfunction across the cognitively normal to MCI to AD continuum. MCS is normalised to unity per subject via modality ablation (MCS_MRI_i + MCS_PET_i = 1.0 for every subject i), providing an interpretable, clinically actionable score that fluid biomarkers cannot supply. Applied to 327 ADNI-3 participants balanced across cognitively normal, mild cognitive impairment, and AD groups, MCNet achieved competitive three-class staging performance (AUC=0.881). The MCS revealed a statistically significant monotonic gradient (Kruskal-Wallis p<0.0001), with increasing PET dominance from cognitively normal (MCS_PET 0.412+/-0.229) through MCI (0.489+/-0.289) to AD (0.671+/-0.426), validated against amyloid SUVR (r=0.172, p=0.006) and FDG metabolic biomarkers (r=-0.287, p=0.0005) from separate imaging pipelines. External replication in 1,073 independent OASIS-3 subjects confirmed cross-cohort generalisability (H=166.99, p<0.0001, eta^2=0.156). A mechanistic comparison with SHAP demonstrated that ablation-based MCS captures clinically meaningful modality dependence that deviation-based methods cannot. These findings position MCNet as a foundation for personalised imaging decisions, clinical trial stratification, and trustworthy AI in dementia care.

Which Modality Decides? Counterfactual Modality Attribution for Multimodal LLMs

Multimodal large language models (MLLMs) increasingly support high-stakes decision making by combining complementary information from images and text. While existing explainability methods identify influential image regions or text tokens, they cannot answer a fundamental question: which modality drives a prediction? Consequently, a model may produce the correct output while relying on the wrong source of evidence, masking shortcut learning and unsafe reasoning. We formulate modality attribution as a complementary explainability objective for multimodal foundation models and propose Counterfactual Modality Attribution (CMA), the first framework for quantifying modality-level contributions in MLLMs. CMA generates image-only, text-only, and joint multimodal counterfactuals using coupled diffusion priors and converts them into principled modality attribution scores through a cooperative game-theoretic formulation based on Shapley values. We evaluate CMA on controlled synthetic benchmarks with known ground-truth modality reliance and on a real-world multimodal clinical dataset. CMA correctly identifies the decision-driving modality in 98% of controlled cases and consistently outperforms baselines, revealing failures of cross-modal reasoning that remain invisible to predictive accuracy alone. Our results establish modality attribution as a complementary dimension of explainability beyond feature attribution, providing a principled framework for auditing multimodal foundation models in safety-critical applications.