Benchmarking and Explaining Deep Learning Cortical Lesion MRI Segmentation in Multiple Sclerosis

Cortical lesions (CLs) have emerged as valuable biomarkers in multiple sclerosis (MS), offering high diagnostic specificity and prognostic relevance. However, their routine clinical integration remains limited due to subtle magnetic resonance imaging (MRI) appearance, challenges in expert annotation, and a lack of standardized automated methods. We propose a comprehensive multi-centric benchmark of CL detection and segmentation in MRI. A total of 656 MRI scans, including clinical trial and research data from four institutions, were acquired at 3T and 7T using MP2RAGE and MPRAGE sequences with expert-consensus annotations. We rely on the self-configuring nnU-Net framework, designed for medical imaging segmentation, and propose adaptations tailored to the improved CL detection. We evaluated model generalization through out-of-distribution testing, demonstrating strong lesion detection capabilities with an F1-score of 0.64 and 0.5 in and out of the domain, respectively. We also analyze internal model features and model errors for a better understanding of AI decision-making. Our study examines how data variability, lesion ambiguity, and protocol differences impact model performance, offering future recommendations to address these barriers to clinical adoption. To reinforce the reproducibility, the implementation and models will be publicly accessible and ready to use at https://github.com/Medical-Image-Analysis-Laboratory/ and https://doi.org/10.5281/zenodo.15911797.

Monitoring morphometric drift in lifelong learning segmentation of the spinal cord

Morphometric measures derived from spinal cord segmentations can serve as diagnostic and prognostic biomarkers in neurological diseases and injuries affecting the spinal cord. While robust, automatic segmentation methods to a wide variety of contrasts and pathologies have been developed over the past few years, whether their predictions are stable as the model is updated using new datasets has not been assessed. This is particularly important for deriving normative values from healthy participants. In this study, we present a spinal cord segmentation model trained on a multisite $(n=75)$ dataset, including 9 different MRI contrasts and several spinal cord pathologies. We also introduce a lifelong learning framework to automatically monitor the morphometric drift as the model is updated using additional datasets. The framework is triggered by an automatic GitHub Actions workflow every time a new model is created, recording the morphometric values derived from the model's predictions over time. As a real-world application of the proposed framework, we employed the spinal cord segmentation model to update a recently-introduced normative database of healthy participants containing commonly used measures of spinal cord morphometry. Results showed that: (i) our model outperforms previous versions and pathology-specific models on challenging lumbar spinal cord cases, achieving an average Dice score of $0.95 \pm 0.03$; (ii) the automatic workflow for monitoring morphometric drift provides a quick feedback loop for developing future segmentation models; and (iii) the scaling factor required to update the database of morphometric measures is nearly constant among slices across the given vertebral levels, showing minimum drift between the current and previous versions of the model monitored by the framework. The model is freely available in Spinal Cord Toolbox v7.0.

Explainability of AI Uncertainty: Application to Multiple Sclerosis Lesion Segmentation on MRI

Trustworthy artificial intelligence (AI) is essential in healthcare, particularly for high-stakes tasks like medical image segmentation. Explainable AI and uncertainty quantification significantly enhance AI reliability by addressing key attributes such as robustness, usability, and explainability. Despite extensive technical advances in uncertainty quantification for medical imaging, understanding the clinical informativeness and interpretability of uncertainty remains limited. This study introduces a novel framework to explain the potential sources of predictive uncertainty, specifically in cortical lesion segmentation in multiple sclerosis using deep ensembles. The proposed analysis shifts the focus from the uncertainty-error relationship towards relevant medical and engineering factors. Our findings reveal that instance-wise uncertainty is strongly related to lesion size, shape, and cortical involvement. Expert rater feedback confirms that similar factors impede annotator confidence. Evaluations conducted on two datasets (206 patients, almost 2000 lesions) under both in-domain and distribution-shift conditions highlight the utility of the framework in different scenarios.

Interpretability of Uncertainty: Exploring Cortical Lesion Segmentation in Multiple Sclerosis

Uncertainty quantification (UQ) has become critical for evaluating the reliability of artificial intelligence systems, especially in medical image segmentation. This study addresses the interpretability of instance-wise uncertainty values in deep learning models for focal lesion segmentation in magnetic resonance imaging, specifically cortical lesion (CL) segmentation in multiple sclerosis. CL segmentation presents several challenges, including the complexity of manual segmentation, high variability in annotation, data scarcity, and class imbalance, all of which contribute to aleatoric and epistemic uncertainty. We explore how UQ can be used not only to assess prediction reliability but also to provide insights into model behavior, detect biases, and verify the accuracy of UQ methods. Our research demonstrates the potential of instance-wise uncertainty values to offer post hoc global model explanations, serving as a sanity check for the model. The implementation is available at https://github.com/NataliiaMolch/interpret-lesion-unc.

Instance-level quantitative saliency in multiple sclerosis lesion segmentation

In recent years, explainable methods for artificial intelligence (XAI) have tried to reveal and describe models' decision mechanisms in the case of classification tasks. However, XAI for semantic segmentation and in particular for single instances has been little studied to date. Understanding the process underlying automatic segmentation of single instances is crucial to reveal what information was used to detect and segment a given object of interest. In this study, we proposed two instance-level explanation maps for semantic segmentation based on SmoothGrad and Grad-CAM++ methods. Then, we investigated their relevance for the detection and segmentation of white matter lesions (WML), a magnetic resonance imaging (MRI) biomarker in multiple sclerosis (MS). 687 patients diagnosed with MS for a total of 4043 FLAIR and MPRAGE MRI scans were collected at the University Hospital of Basel, Switzerland. Data were randomly split into training, validation and test sets to train a 3D U-Net for MS lesion segmentation. We observed 3050 true positive (TP), 1818 false positive (FP), and 789 false negative (FN) cases. We generated instance-level explanation maps for semantic segmentation, by developing two XAI methods based on SmoothGrad and Grad-CAM++. We investigated: 1) the distribution of gradients in saliency maps with respect to both input MRI sequences; 2) the model's response in the case of synthetic lesions; 3) the amount of perilesional tissue needed by the model to segment a lesion. Saliency maps (based on SmoothGrad) in FLAIR showed positive values inside a lesion and negative in its neighborhood. Peak values of saliency maps generated for these four groups of volumes presented distributions that differ significantly from one another, suggesting a quantitative nature of the proposed saliency. Contextual information of 7mm around the lesion border was required for their segmentation.

Denoising Diffusion Models for 3D Healthy Brain Tissue Inpainting

Monitoring diseases that affect the brain's structural integrity requires automated analysis of magnetic resonance (MR) images, e.g., for the evaluation of volumetric changes. However, many of the evaluation tools are optimized for analyzing healthy tissue. To enable the evaluation of scans containing pathological tissue, it is therefore required to restore healthy tissue in the pathological areas. In this work, we explore and extend denoising diffusion models for consistent inpainting of healthy 3D brain tissue. We modify state-of-the-art 2D, pseudo-3D, and 3D methods working in the image space, as well as 3D latent and 3D wavelet diffusion models, and train them to synthesize healthy brain tissue. Our evaluation shows that the pseudo-3D model performs best regarding the structural-similarity index, peak signal-to-noise ratio, and mean squared error. To emphasize the clinical relevance, we fine-tune this model on data containing synthetic MS lesions and evaluate it on a downstream brain tissue segmentation task, whereby it outperforms the established FMRIB Software Library (FSL) lesion-filling method.

Structural-Based Uncertainty in Deep Learning Across Anatomical Scales: Analysis in White Matter Lesion Segmentation

This paper explores uncertainty quantification (UQ) as an indicator of the trustworthiness of automated deep-learning (DL) tools in the context of white matter lesion (WML) segmentation from magnetic resonance imaging (MRI) scans of multiple sclerosis (MS) patients. Our study focuses on two principal aspects of uncertainty in structured output segmentation tasks. Firstly, we postulate that a good uncertainty measure should indicate predictions likely to be incorrect with high uncertainty values. Second, we investigate the merit of quantifying uncertainty at different anatomical scales (voxel, lesion, or patient). We hypothesize that uncertainty at each scale is related to specific types of errors. Our study aims to confirm this relationship by conducting separate analyses for in-domain and out-of-domain settings. Our primary methodological contributions are (i) the development of novel measures for quantifying uncertainty at lesion and patient scales, derived from structural prediction discrepancies, and (ii) the extension of an error retention curve analysis framework to facilitate the evaluation of UQ performance at both lesion and patient scales. The results from a multi-centric MRI dataset of 172 patients demonstrate that our proposed measures more effectively capture model errors at the lesion and patient scales compared to measures that average voxel-scale uncertainty values. We provide the UQ protocols code at https://github.com/Medical-Image-Analysis-Laboratory/MS_WML_uncs.

Towards contrast-agnostic soft segmentation of the spinal cord

Spinal cord segmentation is clinically relevant and is notably used to compute spinal cord cross-sectional area (CSA) for the diagnosis and monitoring of cord compression or neurodegenerative diseases such as multiple sclerosis. While several semi and automatic methods exist, one key limitation remains: the segmentation depends on the MRI contrast, resulting in different CSA across contrasts. This is partly due to the varying appearance of the boundary between the spinal cord and the cerebrospinal fluid that depends on the sequence and acquisition parameters. This contrast-sensitive CSA adds variability in multi-center studies where protocols can vary, reducing the sensitivity to detect subtle atrophies. Moreover, existing methods enhance the CSA variability by training one model per contrast, while also producing binary masks that do not account for partial volume effects. In this work, we present a deep learning-based method that produces soft segmentations of the spinal cord. Using the Spine Generic Public Database of healthy participants ($\text{n}=267$; $\text{contrasts}=6$), we first generated participant-wise soft ground truth (GT) by averaging the binary segmentations across all 6 contrasts. These soft GT, along with a regression-based loss function, were then used to train a UNet model for spinal cord segmentation. We evaluated our model against state-of-the-art methods and performed ablation studies involving different GT mask types, loss functions, and contrast-specific models. Our results show that using the soft average segmentations along with a regression loss function reduces CSA variability ($p < 0.05$, Wilcoxon signed-rank test). The proposed spinal cord segmentation model generalizes better than the state-of-the-art contrast-specific methods amongst unseen datasets, vendors, contrasts, and pathologies (compression, lesions), while accounting for partial volume effects.

GAMER-MRIL identifies Disability-Related Brain Changes in Multiple Sclerosis

Objective: Identifying disability-related brain changes is important for multiple sclerosis (MS) patients. Currently, there is no clear understanding about which pathological features drive disability in single MS patients. In this work, we propose a novel comprehensive approach, GAMER-MRIL, leveraging whole-brain quantitative MRI (qMRI), convolutional neural network (CNN), and an interpretability method from classifying MS patients with severe disability to investigating relevant pathological brain changes. Methods: One-hundred-sixty-six MS patients underwent 3T MRI acquisitions. qMRI informative of microstructural brain properties was reconstructed, including quantitative T1 (qT1), myelin water fraction (MWF), and neurite density index (NDI). To fully utilize the qMRI, GAMER-MRIL extended a gated-attention-based CNN (GAMER-MRI), which was developed to select patch-based qMRI important for a given task/question, to the whole-brain image. To find out disability-related brain regions, GAMER-MRIL modified a structure-aware interpretability method, Layer-wise Relevance Propagation (LRP), to incorporate qMRI. Results: The test performance was AUC=0.885. qT1 was the most sensitive measure related to disability, followed by NDI. The proposed LRP approach obtained more specifically relevant regions than other interpretability methods, including the saliency map, the integrated gradients, and the original LRP. The relevant regions included the corticospinal tract, where average qT1 and NDI significantly correlated with patients' disability scores ($\rho$=-0.37 and 0.44). Conclusion: These results demonstrated that GAMER-MRIL can classify patients with severe disability using qMRI and subsequently identify brain regions potentially important to the integrity of the mobile function. Significance: GAMER-MRIL holds promise for developing biomarkers and increasing clinicians' trust in NN.

Diffusion Models for Contrast Harmonization of Magnetic Resonance Images

Magnetic resonance (MR) images from multiple sources often show differences in image contrast related to acquisition settings or the used scanner type. For long-term studies, longitudinal comparability is essential but can be impaired by these contrast differences, leading to biased results when using automated evaluation tools. This study presents a diffusion model-based approach for contrast harmonization. We use a data set consisting of scans of 18 Multiple Sclerosis patients and 22 healthy controls. Each subject was scanned in two MR scanners of different magnetic field strengths (1.5 T and 3 T), resulting in a paired data set that shows scanner-inherent differences. We map images from the source contrast to the target contrast for both directions, from 3 T to 1.5 T and from 1.5 T to 3 T. As we only want to change the contrast, not the anatomical information, our method uses the original image to guide the image-to-image translation process by adding structural information. The aim is that the mapped scans display increased comparability with scans of the target contrast for downstream tasks. We evaluate this method for the task of segmentation of cerebrospinal fluid, grey matter and white matter. Our method achieves good and consistent results for both directions of the mapping.