Adaptive Post-Processing Drives Instance-Level Detection in Stroke Lesion Segmentation

Chronic ischemic stroke lesions are difficult to segment on T1-weighted MRI. Their appearance overlaps with healthy tissue, and their volumes span four orders of magnitude, so voxel-level and lesion level metrics often disagree. We build an eleven-member nnU-Net ensemble that covers five design axes: a baseline dice + top-K loss, heavy augmentation, per-lesion volume loss re-weighting, stochastic weight averaging, and a sampling-and-architecture block that pairs cohort-balanced sampling with a residual-encoder backbone. Weighted soft-map fusion of the members feeds a tuned decision layer, SADL, that estimates lesion volume, applies an adaptive per-lesion-size threshold, prunes components by voxel count and peak probability, and adds a never-empty rescue. All fusion weights and per-bucket parameters are fitted on out-of-fold (OOF) predictions, so tuning never touches the held-out test set. On a site-disjoint 91-case holdout, SADL reaches Dice 0.7322, lesion-F1 0.7461 and PR-AUC 0.8430 when scored online with the challenge's released evaluation code. A paired non-parametric bootstrap against a reference single ensemble member confirms the lesion-F1 gain at p=0.024, and the gain is largest in the small-lesion regime, where the rescue step recovers cases that a fixed threshold would silently discard.

Small lesions in brain MRI are hard to segment because they occupy a tiny fraction of the volume and are dominated by background and larger lesions during voxel-wise optimization, so a model can reach a high Dice similarity coefficient (DSC) while missing many of them. We propose CATMIL, a training objective that adds two auxiliary terms to the standard nnU-Net Dice and cross-entropy loss without changing the architecture. The Component-Adaptive Tversky (CAT) term weights lesion voxels by the inverse size of their connected component, so each lesion contributes nearly equally regardless of volume. The lesion-level Multiple Instance Learning (MIL) term treats each lesion as a bag of voxels and penalizes lesions with no detected voxel. For multiple sclerosis lesion segmentation on MSLesSeg, CATMIL achieves the highest small-lesion recall (0.873 vs. 0.796 for Dice+CE; 95% CI of the difference +0.030 to +0.157, higher in all six test patients) and about 48% fewer missed lesions, with comparable DSC and HD95. The gain holds for lesions of at least 3 mm in diameter, the clinical reading size (recall 0.944 vs. 0.870). Standard losses produce no probability response to most small lesions they miss, so no threshold can recover them. The cost is more small false-positive components; a simple component-size filter removes most of them while keeping the sensitivity gain, and at matched lesion-wise precision CATMIL detects more small lesions with higher lesion-wise F1. An ablation attributes the detection gain to the MIL term. On a second dataset, 3D-MR-MS, CATMIL with the same loss weights again improves small-lesion recall, at a larger false-positive cost and slightly lower DSC. Code: https://github.com/luumsk/SmallLesionMRI

Large networks and ensembles often lead medical image segmentation challenges, but their storage and inference demands complicate deployment. We present LightMedSeg-ISLES, a 1.26-million-parameter pipeline for T1-weighted stroke lesion segmentation in ISLES'26. On a 146-case held-out cohort, flip test-time augmentation produces 0.618 mean Dice and 0.599 lesion-wise F1. A 102.35-million-parameter nnU-Net ResEnc-L produces 0.634 Dice and 0.544 lesion-wise F1 after size filtering. LightMedSeg therefore retains 97.5% of nnU-Net's Dice with 81.4$\times$ fewer parameters while improving lesion-wise F1 by 0.055. Its four-pass TTA operating point requires 4.7$\times$ fewer FLOPs per standardized patch than nnU-Net. It also slightly exceeds filtered UNETR++ and nnFormer. Longer training and stronger augmentation add 0.0358 Dice without increasing capacity, establishing a strong single-checkpoint alternative to much larger models.