Triggering hallucinations in model-based MRI reconstruction via adversarial perturbations

Artificial intelligence (AI) has transformed imaging inverse problems, from medical diagnostics to Earth observation. Yet deep neural networks can produce hallucinations, realistic-looking but incorrect details, undermining their reliability, especially when ground truth data is unavailable. We develop a theoretical framework showing that such hallucinations are not merely artifacts of particular models, but can arise from the ill-posed nature of the inverse problem itself. We derive necessary and sufficient conditions for hallucinations, together with computable bounds on their magnitude that depend only on the forward model. Building on this theory, we introduce algorithms to: (1) estimate the minimum hallucination magnitude achievable by any reconstruction model for a given input; (2) assess the faithfulness of reconstructed details by a given reconstruction model. Experiments across three imaging tasks demonstrate that our approach applies broadly, including to modern generative models, and provides a principled way to quantify and evaluate AI hallucinations.

AI systems are being deployed across medical imaging faster than their failure modes are understood. At this point in time, the failure of greatest clinical concern is hallucination: clinically plausible but factually incorrect outputs, including fabricated anatomical structures, missed findings, incorrect laterality, and invented measurements in generated reports, with direct consequences, for example, for biopsy decisions, staging, and treatment planning. This structured narrative synthesizes peer-reviewed studies, benchmark datasets, and FDA regulatory guidance across five imaging modalities to produce a cross-modality analysis of hallucination taxonomy, etiology, detection, and mitigation. Specifically, we address three questions in this study: (1) how can existing taxonomies be unified across modalities?, (2) how do medical-specialized foundation models hallucinate less than general-purpose ones?, and (3) which mitigation strategies are effective and compatible with FDA lifecycle oversight? We note that three taxonomic frameworks together cover the imaging pipeline in a way no single framework does alone. We also highlight that general-purpose foundation models outperform medical-specialized models on hallucination-specific benchmarks, indicating that narrow domain fine-tuning can introduce overfitting-induced confabulation. At the same time, the oversight of radiologists remains essential; for instance, a very high percentage of of AI-generated flags required expert correction before clinical use. Physics-informed architectural constraints, Chain-of-Thought prompting, and human-in-the-loop safeguards each address different failure modes and is effective when combined. All findings are mapped to the FDA's Total Product Lifecycle and Predetermined Change Control Plan frameworks, which treat hallucination management as a lifecycle obligation rather than a pre-deployment checklist.

Objective: Deep learning accelerates brain MRI four- to tenfold, but models can erase lesions or synthesize false tissue - failures pixel-averaged metrics like PSNR and SSIM miss. We review whether current evaluation practices detect this blind spot. Methods: Following PRISMA 2020, we searched seven databases without date limits, including 263 studies (1995-2026), appraised them using QUADAS-2 and matched instruments, and synthesized narratively. Categories were derived from titles, abstracts, and controlled vocabulary; reported prevalence figures represent floors. Duplicate screening achieved high agreement (Fleiss kappa = 0.877), as did appraisal (0.788; 0.390 where observable). Extraction is unaudited. Results: Only 18 of 263 studies (6.8%) recorded both a fidelity metric and reader assessment on identical data, leaving the central surrogate unmeasured. Reader studies mostly measured inter-reader agreement, which was weak: fastMRI 2020 concordance reached 0.457 and 0.386 (Kendall W), improving only where SSIM diverged. Erasing a 100 mm3 lacunar infarct shifts global PSNR by 0.03 dB under the stated error model. As the corpus grew fivefold, reader assessments dropped from 32% to 18%, recovering to 21%. Generative models - most associated with hallucination (39%) - were among the least reader-evaluated (11.3%), while self-supervised models reached 47% with zero reader evaluation. Only 5% released code and ran reader studies; none evaluated a model observer; no named dataset covered acute stroke or hemorrhage. Conclusions: On these floors, current evaluation practices cannot certify diagnostic safety. We derive five requirements safety-oriented evaluations must meet.