Predicting brain tumour enhancement from non-contrast MR imaging with artificial intelligence: a multi-cohort retrospective diagnostic accuracy study

Brain tumour MRI typically requires both pre- and post-contrast imaging, but gadolinium is not always desirable (frequent follow-up, renal impairment, allergy, paediatric patients). We developed and validated a deep learning model to predict tumour contrast enhancement from non-contrast MRI alone. We assembled 11,089 brain MRI studies (2006-2024) from 10 datasets across four countries and three continents, spanning adult and paediatric populations with glioma, meningioma, metastases, and post-resection appearances. Three architectures were trained to detect and segment enhancing tumour from T1w, T2w and FLAIR alone. Performance was assessed in a 1,109-study held-out test set (primary endpoint: patient-level enhancement detection; secondary: voxel-level Dice). Eleven expert radiologists attempted the same task on a 564-case subset (100 cases each), blinded to history, prior imaging, and referral. The best model, nnU-Net, achieved 83.0% balanced accuracy (95% CI 79.1-87.2; sensitivity 91.5%, specificity 74.4%) for detection, with R2 = 0.859 for enhancement volume. Of enhancing cases, 76.8% reached Dice >= 0.3, 67.5% >= 0.5, and 50.2% >= 0.7. Under blinded conditions, radiologists' majority vote was lower (71.7% balanced accuracy; sensitivity 77.6%, specificity 65.8%). The proportion reaching Dice >= 0.3 varied by pathology (meningioma 93%, presurgical glioma 76%, metastases 74%, postoperative glioma 74%) and was lowest for paediatric cases (45%). Deep learning can identify contrast-enhancing brain tumours from non-contrast MRI. These models show promise as a triage or decision-support adjunct, such as in flagging studies likely to enhance so that contrast can be added to a non-contrast protocol, and may reduce gadolinium dependence in neuro-oncology imaging. Future work should optimise these models with radiologists.