Improving Factuality of 3D Brain MRI Report Generation with Paired Image-domain Retrieval and Text-domain Augmentation

Acute ischemic stroke (AIS) requires time-critical decision-making, where inaccurate interpretation of neuroimaging findings can lead to irreversible disability. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps from magnetic resonance imaging (MRI) are central to detecting acute infarction, yet generating factually reliable radiology reports directly from 3D MRI remains challenging due to the difficulty of learning robust cross-modal alignments between volumetric images and clinical text. We propose paired image-domain retrieval and text-domain augmentation (PIRTA), a retrieval-augmented generation framework that improves report factuality by avoiding explicit image-text alignment. PIRTA retrieves clinically similar 3D DWI/ADC volumes using a pretrained 3D vision encoder and leverages their paired clinician-authored reports to ground large language model (LLM)-based report generation. Experiments on multi-institutional in-house data, a held-out external privacy-preserving cohort, and the public ISLES benchmark demonstrate that PIRTA achieves strong image-domain retrieval performance and consistently improves ischemic-territory accuracy, a clinically grounded surrogate for report factuality, compared to direct image-to-text baselines. These results indicate that retrieval-grounded generation provides a scalable and reliable paradigm for producing factually consistent radiology reports from complex 3D brain MRI. Source code is available at https://github.com/jhlee0619/PIRTA.