Synthesizing Accurate and Realistic T1-weighted Contrast-Enhanced MR Images using Posterior-Mean Rectified Flow

Contrast-enhanced (CE) T1-weighted MRI is central to neuro-oncologic diagnosis but requires gadolinium-based agents, which add cost and scan time, raise environmental concerns, and may pose risks to patients. In this work, we propose a two-stage Posterior-Mean Rectified Flow (PMRF) pipeline for synthesizing volumetric CE brain MRI from non-contrast inputs. First, a patch-based 3D U-Net predicts the voxel-wise posterior mean (minimizing MSE). Then, this initial estimate is refined by a time-conditioned 3D rectified flow to incorporate realistic textures without compromising structural fidelity. We train this model on a multi-institutional collection of paired pre- and post-contrast T1w volumes (BraTS 2023-2025). On a held-out test set of 360 diverse volumes, our best refined outputs achieve an axial FID of $12.46$ and KID of $0.007$ ($\sim 68.7\%$ lower FID than the posterior mean) while maintaining low volumetric MSE of $0.057$ ($\sim 27\%$ higher than the posterior mean). Qualitative comparisons confirm that our method restores lesion margins and vascular details realistically, effectively navigating the perception-distortion trade-off for clinical deployment.