Imagining Alternatives: Towards High-Resolution 3D Counterfactual Medical Image Generation via Language Guidance

Vision-language models have demonstrated impressive capabilities in generating 2D images under various conditions; however, the success of these models is largely enabled by extensive, readily available pretrained foundation models. Critically, comparable pretrained models do not exist for 3D, significantly limiting progress. As a result, the potential of vision-language models to produce high-resolution 3D counterfactual medical images conditioned solely on natural language remains unexplored. Addressing this gap would enable powerful clinical and research applications, such as personalized counterfactual explanations, simulation of disease progression, and enhanced medical training by visualizing hypothetical conditions in realistic detail. Our work takes a step toward this challenge by introducing a framework capable of generating high-resolution 3D counterfactual medical images of synthesized patients guided by free-form language prompts. We adapt state-of-the-art 3D diffusion models with enhancements from Simple Diffusion and incorporate augmented conditioning to improve text alignment and image quality. To our knowledge, this is the first demonstration of a language-guided native-3D diffusion model applied to neurological imaging, where faithful three-dimensional modeling is essential. On two neurological MRI datasets, our framework simulates varying counterfactual lesion loads in Multiple Sclerosis and cognitive states in Alzheimer's disease, generating high-quality images while preserving subject fidelity. Our results lay the groundwork for prompt-driven disease progression analysis in 3D medical imaging. Project link - https://lesupermomo.github.io/imagining-alternatives/.