CATCH: Counterfactual Anatomical Tissue Inpainting with Conditional Haar Diffusion

The ASNR-MICCAI BraTS Local Synthesis (Inpainting) task asks for the anatomically plausible completion of healthy brain tissue within a masked region of a T1-weighted MRI, providing a tumor-free anatomical reference for downstream analysis. As the task is scored by distortion metrics (SSIM, PSNR, MSE), we build a deterministic regression model and focus on giving it inductive biases tailored to inpainting. Our network follows the U-DiT principle of performing self-attention on a downsampled token grid: a volumetric encoder-decoder imports long-range context through a downsampled global self-attention block with three-dimensional rotary position embeddings, while convolutions and skip connections preserve high-frequency detail. Two ideas drive our results. First, we constrain the attention so that occluded ("void") tokens attend only to known-healthy tokens of the same volume, with a learned bias toward each query's contralateral homologue, forcing the completion to be inferred from observed anatomy rather than from other unknown regions. Second, we add a contralateral-symmetry input that supplies the mirrored healthy hemisphere as a patient-specific prior; since the brain is approximately bilaterally symmetric and lesions are typically unilateral, this prior improves the distortion metrics at matched structural similarity. On the official BraTS-2026 validation leaderboard our submission reaches a mean healthy-region SSIM of $0.864$, PSNR of $24.7$,dB and MSE of $4.6{\times}10^{-3}$ over $219$ cases. We further analyse the residual smoothness inherent to distortion-optimal regression and discuss its implications for anatomical realism.

Medical image inpainting has the potential to improve automated brain MRI analysis by reconstructing healthy tissue within pathological regions. We introduce RARF, a task-agnostic region-aware rectified flow framework for masked data generation. We instantiate the framework for 3D brain MRI inpainting as our submission to the BraTS Inpainting Challenge 2026. RARF restricts the stochastic interpolation process to the inpainting region, while the observed voxels remain fixed and provide patient-specific anatomical context. A three-dimensional neural network receives the partially voided image, with Gaussian noise filling the missing region, together with the inpainting mask and the corresponding timestep. The model is trained using masked flow-matching and reconstruction-consistency objectives, combined with mask-aware preprocessing and data augmentation. During inference, the learned velocity field transports the initial noise toward a plausible reconstruction of the missing tissue, which is then combined with the unchanged observed anatomy. Experiments under the BraTS evaluation protocol show that the proposed approach produces competitive reconstructions while maintaining anatomical consistency. Source code is available at: https://github.com/TomasGuija/rarf.

Brain-MRI inpainting replaces a masked region of a scan with synthesized, anatomically plausible healthy tissue, so that analysis tools built for healthy brains can be applied to images they would otherwise reject. On the BraTS local-synthesis benchmark, which ranks submissions on the structural similarity index (SSIM), the peak signal-to-noise ratio, and the mean squared error (MSE) jointly, the strongest recent models are accurate, but several report blurry synthesized regions and attribute this to the mean-seeking behavior of the $\ell_1$ and MSE terms in their training losses. We address this in post-processing, forming a deep ensemble of the two co-first-place 2025 models and training a lightweight residual refiner on the ensemble's own outputs under an $\ell_1$ loss augmented with a structural-similarity term whose weight $λ$ we vary. At a moderate $λ$ the refiner improves SSIM over the ensemble, from $0.8767$ to $0.8780$ on a held-out reproduction of the official scorer and from $0.8555$ to $0.8572$ on the official validation leaderboard, with essentially no change in MSE. The gain is small but consistent, improving $62.6\%$ of the held-out cases with a signed-rank $p=2.2\times10^{-7}$, whereas over-weighting the structural term reverses it. Two ablations bound the effect. Adding any third model to the two-model ensemble degrades it, and classical unsharp masking fails to improve SSIM at any strength (best $0.8765$ against $0.8767$), so the gain reflects learned rather than indiscriminate sharpening. The result is a cheap, reproducible post-processing stage that improves an already strong ensemble without any large-scale retraining.