Component-Adaptive and Lesion-Level Supervision for Improved Small Structure Segmentation in Brain MRI

Common segmentation losses aggregate errors voxel-wise, so lesions influence the objective in proportion to their volume, giving small but clinically critical lesions disproportionately little weight. Instance-aware losses aim to address this mismatch by assigning each lesion its own term. However, blob loss and CC-DiceCE derive their regions solely from annotations, so false-positive components receive no instance-level term. This matters in computer-assisted review, where each false-positive component may require separate inspection, making precision and false-positive burden important alongside recall. We introduce the bidirectional connected-component loss (BiCC), which pairs annotation- and prediction-derived partitions to score predicted components on their own scale. By deriving instances from the predictions, this branch directly penalizes false-positive components regardless of their size. The balance parameter $α$ allows control over the lesion-wise precision-recall trade-off. Across five datasets with five-fold cross-validation using nnU-Net, BiCC outperforms CC-DiceCE in lesion-wise F1 on four datasets and blob loss on all five. It significantly improves over DiceCE on three datasets and matches it on two; CC-DiceCE instead loses up to 0.363 precision by favoring recall. Code is available at https://github.com/TIO-IKIM/BiCC-Loss.

Accurate and generalisable segmentation of stroke lesions from magnetic resonance imaging (MRI) is essential for advancing clinical research, prognostic modelling, and personalised interventions. Although deep learning has improved automated lesion delineation, many existing models are optimised for narrow imaging contexts and generalise poorly to independent datasets, modalities, and stroke stages. Here, we systematically evaluated stroke lesion segmentation using the nnU-Net framework across multiple heterogeneous, publicly available MRI datasets spanning acute and chronic stroke. Models were trained and tested on diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), and T1-weighted MRI, and evaluated on independent datasets. Across stroke stages, models showed robust generalisation, with segmentation accuracy approaching reported inter-rater reliability. Performance varied with imaging modality and training data characteristics. In acute stroke, DWI-trained models consistently outperformed FLAIR-based models, with only modest gains from multimodal combinations. In chronic stroke, increasing training set size improved performance, with diminishing returns beyond several hundred cases. Lesion volume was a key determinant of accuracy: smaller lesions were harder to segment, and models trained on restricted volume ranges generalised poorly. MRI image quality further constrained generalisability: models trained on lower-quality scans transferred poorly, whereas those trained on higher-quality data generalised well to noisier images. Discrepancies between predictions and reference masks were often attributable to limitations in manual annotations. Together, these findings show that automated lesion segmentation can approach human-level performance while identifying key factors governing generalisability and informing the development of lesion segmentation tools.

The segmentation of lesions in Moderate to Severe Traumatic Brain Injury (msTBI) from T1-weighted MRI presents a significant clinical challenge due to the profound heterogeneity of lesion characteristics in terms of size, shape, and location. To address this, the AIMS-TBI 2025 Challenge was organized to promote the development of robust and accurate segmentation algorithms. In this paper, we present our deep learning-based solution. Our methodology employs the nnU-Net framework with an adaptive intensity normalization strategy confined to the brain parenchyma, effectively reducing inter-subject variability and mitigating artifacts from non-brain structures. Upon final evaluation on the held-out test set, our method demonstrated highly competitive performance on the official leaderboard, achieving an Overall Dice Coefficient of 0.6305. The model obtained a Dice score of 0.4805 for lesion segmentation and 0.9324 for non-lesion tissue. While the lesion Dice reflects the difficulty of detecting highly heterogeneous lesions, the high non-lesion Dice primarily indicates the model's strong ability to correctly identify non-lesion voxels, demonstrating good specificity in differentiating lesion from non-lesion regions. These results demonstrate that incorporating anatomically constrained normalization within the nnU-Net pipeline is a powerful and effective strategy for tackling the complexities of msTBI lesion segmentation.