CARVE: Cross-Slice Anisotropic Reallocation of Visual Evidence for Efficient 3D Medical Volume Understanding

Slice-based MLLMs leverage mature 2D encoders by representing 3D volumes as sequences of 2D slices. However, this slice-wise formulation produces thousands of visual tokens that burden the LLM backbone, many of which capture overlapping visual evidence across adjacent slices. To understand how effectively a growing visual token budget improves performance, we perform scaling analyses on two 3D medical VQA benchmarks and find diminishing returns: cost keeps rising while accuracy saturates, and improving in-plane resolution is more effective than adding slices at comparable budgets. The budget should therefore be allocated more selectively rather than simply enlarged, yet most token compression methods are designed for 2D images or videos, where redundancy arises from spatial layout or temporal motion rather than from near-duplicate content along the depth axis. We present CARVE, a training-free framework that compresses visual tokens prior to LLM inference and casts token reduction as budget-constrained 2.5D allocation. CARVE partitions the depth axis into coherent windows and allocates tokens non-uniformly according to normalized cross-slice evidence. Under a shared budget, CARVE builds spatial anchors on representative slices and retrieves locally varying evidence from the full volume, then merges remaining eligible tokens into nearby anchors within each window. Removing roughly 80% of the visual tokens on Hulu-Med-7B, CARVE leads all compression baselines on every AMOS-MM report-generation metric, with 6.2 points higher retention of full-token quality than the strongest baseline, and preserves 98.1% of full-token performance across three VQA benchmarks.

Brain-Adapter: A Dual-Stream Vision-Language MIL Framework for Comprehensive 3D CT Diagnosis of Acute Intracranial Pathologies

Automated diagnosis of 3D brain CT scans is essential for critical care, yet it remains challenging due to the heavy reliance on manual annotations and the limited semantic understanding of conventional models. While 2D foundation vision-language models (VLMs) have shown remarkable generalization, effectively transferring their representational power to 3D volumes remains an open problem. In this paper, we propose Brain-Adapter, a novel dual-stream multiple instance learning (MIL) framework that leverages pre-trained 2D biomedical VLMs and raw diagnostic reports for robust scan-level multi-label classification. Specifically, we introduce a Text-Conditioned Attention (TCA) mechanism, utilizing raw diagnostic sentences as semantic queries to dynamically align visual cues with specific disease concepts. Concurrently, a parallel visual MIL stream captures global scan characteristics, supervised by structured labels extracted via a Large Language Model (LLM). To ensure representation coherence, a consistency constraint enforces synergy between the two streams. During inference, an Uncertainty-Aware Refinement (UAR) module dynamically calibrates and fuses these dual-stream predictions to resolve ambiguous cases. Extensive experiments demonstrate that our method significantly outperforms state-of-the-art 3D models and standard MIL approaches. By eliminating the reliance on dense annotations, Brain-Adapter provides a highly scalable and clinically viable solution for 3D acute intracranial pathology analysis.