MedPruner: Training-Free Hierarchical Token Pruning for Efficient 3D Medical Image Understanding in Vision-Language Models

Integrating 3D medical images with vision-language models (VLMs) holds substantial promise for computer-aided diagnosis. However, volumetric images generate prohibitively long visual-token sequences with considerable spatial and inter-slice redundancy. Existing token compression methods typically apply uniform reduction or rely on a single importance signal, increasing the risk of removing regions that are clinically relevant to the query or structurally distinctive. To address this limitation, we propose MedARC, a unified, training-free framework for Adaptive Redundancy Compression of visual tokens in 3D medical VLMs. MedARC estimates token importance by integrating three complementary cues: self-attention from the VLM vision encoder, which reflects the model's intrinsic visual focus; similarity between projected visual tokens and text embeddings, which identifies query-relevant regions; and deviations of local visual foundation model features from the volume-level feature center, which highlight structurally distinctive anatomy. The resulting importance distribution guides a saliency-aware merging strategy that preserves informative tokens while consolidating redundant ones rather than simply discarding them. Experiments on CT-RATE and MR-RATE show that MedARC reduces visual-token overhead and inference time while preserving or improving diagnostic performance. Its multi-cue scoring cost is outweighed by the savings from processing fewer tokens, with greater benefits expected for larger language models.

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.

While 3D Vision-Language Models (3D VLMs) have demonstrated remarkable spatial reasoning capabilities, they suffer from massive visual token counts that create severe computational bottlenecks during inference. Existing token pruning methods primarily rely on diversity-based selection, discarding similar tokens to maximize dispersion. However, in 3D environments, this approach frequently drops representative prototype tokens in favor of outliers, breaking the multi-view consistencies and geometric structures essential for spatial reasoning. In this paper, we propose a paradigm shift for 3D VLM token pruning: from maximizing diversity to preserving visual evidence coverage. We introduce CoverPrune, a training-free framework that formulates inference-time token pruning as an Optimal Transport (OT) problem. To overcome the intractable combinatorial subset selection inherent in this formulation, we design the Feature-Spatial-Temporal (FST) transport cost and target capacity, along with an efficient Spatial-Guided Greedy Selection (SGS) algorithm to approximate the OT objective. Furthermore, we propose CoverPrune-Lite, an accelerated variant utilizing spatially structured local matching for minimal overhead. Extensive experiments across multiple 3D visual-spatial reasoning benchmarks demonstrate that our methods achieve state-of-the-art token efficiency, maintaining robust reasoning performance even under highly aggressive pruning budgets. Visit our project website at https://github.com/Brucess/CoverPrune.