Training-Free Zero-Shot Anomaly Detection in 3D Brain MRI with 2D Foundation Models

Zero-shot anomaly detection (ZSAD) is attractive for medical imaging because clinical systems must handle heterogeneous acquisition protocols, changing patient populations, and pathologies for which annotated training data may be unavailable. Most existing zero-shot anomaly detection methods are designed for 2D images, and their direct extension to 3D medical volumes is limited by the scarcity of large-scale volumetric foundation models or by the difficulty of utilizing volumetric context. We propose CS3F, a training-free batch-based framework for ZSAD in 3D medical images using 2D foundation models. Each volume is decomposed along multiple anatomical axes and encoded slice-wise by a 2D vision transformer. These are then converted into localized volumetric tokens by pooling neighboring slice features. Anomaly scores are obtained from cross-subject mutual similarity: tokens that lack close analogues in other subjects are assigned higher anomaly scores. To reduce the attenuation of focal lesion signals caused by depth pooling, we introduce a coarse-to-fine tokenization strategy that enables fine-resolution volumetric scoring without exhaustive matching. CS3F is evaluated on brain MRI across metastases, glioma, and stroke, as well as validated on lung CT to test generalizability beyond atlas-aligned brain MRI. The results show that frozen 2D foundation models can support anomaly localization in 3D medical images, and that the benefit of fine tokenization depends strongly on lesion contrast and imaging modality.

Anomaly detection is essential for medical image analysis, where pathological regions often appear as rare deviations from normal anatomical structures. While training-based methods have achieved promising performance, they require task-specific optimization and extensive normal data, which limits scalability across modalities and institutions. Training-free approaches offer greater flexibility by leveraging pretrained visual representations, yet existing methods typically rely on simple nearest-neighbor retrieval and naive aggregation strategies, which may fail to capture hierarchical semantics and ignore the reliability of multiple anomaly responses. In this work, we propose HiMatch-AD, a DINOv3-driven hierarchical matching framework for training-free medical anomaly detection. Our method first retrieves semantically relevant normal references via dual-branch matching that jointly considers global CLS-token similarity and patch-level representations. Hierarchical anomaly maps are then generated across multiple transformer stages by comparing clustered normal features with query representations. To robustly aggregate anomaly responses, we introduce a unified uncertainty-based fusion mechanism that adaptively weights maps according to their reliability. The entire framework operates without any task-specific training. Extensive experiments on the BMAD benchmark, including brain MRI, liver CT, and retinal OCT datasets, demonstrate that HiMatch-AD consistently outperforms both training-based and DINO-based state-of-the-art methods, which highlights the effectiveness of multi-level matching and uncertainty-aware fusion for scalable medical anomaly detection.

Zero-shot anomaly detection (ZSAD) requires detecting and localizing anomalies without access to target-class anomaly samples. Mainstream methods rely on vision-language models (VLMs) such as CLIP: they build hand-crafted or learned prompt sets for normal and abnormal semantics, then compute image-text similarities for open-set discrimination. While effective, this paradigm depends on a text encoder and cross-modal alignment, which can lead to training instability and parameter redundancy. This work revisits the necessity of the text branch in ZSAD and presents VisualAD, a purely visual framework built on Vision Transformers. We introduce two learnable tokens within a frozen backbone to directly encode normality and abnormality. Through multi-layer self-attention, these tokens interact with patch tokens, gradually acquiring high-level notions of normality and anomaly while guiding patches to highlight anomaly-related cues. Additionally, we incorporate a Spatial-Aware Cross-Attention (SCA) module and a lightweight Self-Alignment Function (SAF): SCA injects fine-grained spatial information into the tokens, and SAF recalibrates patch features before anomaly scoring. VisualAD achieves state-of-the-art performance on 13 zero-shot anomaly detection benchmarks spanning industrial and medical domains, and adapts seamlessly to pretrained vision backbones such as the CLIP image encoder and DINOv2. Code: https://github.com/7HHHHH/VisualAD