Component-Adaptive and Lesion-Level Supervision for Improved Small Structure Segmentation in Brain MRI

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