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Results: All tumors were visible on conventional CT, but none appeared on synthetic CT, including densely calcified lesions. Conclusions: BoneMRI synthetic CT is a promising radiation-free alternative, yet currently fails to visualize intradural calcified tumors outside its validated scope, so cautious, development-aligned clinical use is 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\n[https://doi.org/10.1007/s00701-025-06731-0](https://doi.org/10.1007/s00701-025-06731-0)  \nEvaluation of magnetic resonance imaging and deep learning-based synthetic computed tomography for calcified intradural tumors  \n– importance of domain-specific training and validation of synthetic imaging methods for clinical application  \nGregor Fischer1,2 · Felix C. Stengel1,2 · Lorenzo Bertulli1,2 · Linda Bättig1,2 · Victor E. Staartjes3 · Tobias Dietrich4 · Olaf Chan‑Hi Kim4 · Martin N. Stienen3,1,2  \nReceived: 21 May 2025 / Accepted: 18 November 2025 © The Author(s) 2026  \nAbstract  \nPurpose For intradural spinal tumors, information on the degree of calcification is helpful to plan the surgery. Novel deeplearning algorithms allow to generate synthetic computed tomography (CT) images from magnetic resonance imaging (MRI) . Methods We conducted a prospective observational cohort study, including n = 105 patients with spinal pathologies between 07/2022 – 09/2023, to validate the accuracy of BoneMRI (MRIGuidance BV©, Utrecht, the Netherlands) . Patients underwent both conventional CT and MRI; synthetic CT images were generated from MRI source data with artificial intelligence (AI) . For the scope of this post-hoc analysis, only patients with intradural tumors were selected.  \nResults Five patients with intradural tumors of the spine were included (mean age 67.8 years; 4 (80%) female) . The tumors were visible on 5/5 conventional CT images (100%), on average 19.6 × 11.6 mm in size and 4/5 (80%) were densely calcified (mean Hounsfield units (HU) 463.6) . Although well-visible on the T1w/T2w/BoneMRI source data, none of the tumors showed up (0%) on synthetic CT. Visible tumor dimensions were 0 mm in both axial (p \u003C 0.001) and sagittal planes (p = 0.017), with an average density of 20.9 HUs (p = 0.034) .  \nConclusions BoneMRI generated synthetic CT is a promising, radiation-free alternative to conventional CT. Intradural tumors – even those with dense calcifications – were not visualized by synthetic CT images, highlighting that this novel technology is currently not able to capture lesions outside its main scope. Our analysis demonstrates powerfully that synthetic imaging must be cautiously applied to populations for which it was developed and validated, and that any extrapolation can be clinically misleading.  \nKeywords BoneMRI · Intradural tumor · Meningioma · Calcification · Synthetic imaging · AI-generated images  \nAbbreviations  \n* Martin N. Stienen[mnstienen@gmail.com](mnstienen@gmail.com)  \n1 Department of Neurosurgery, H-OCH Health Ostschweiz & St. Gallen Medical School, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland  \n2 Interdisciplinary Spine Center, H-OCH Health Ostschweiz & St. Gallen Medical School, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland  \n3 Machine Intelligence in Clinical Neuroscience & Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, CH-8091 Zurich, Switzerland  \n4 Department of Radiology and Nuclearmedicin, H-OCH Health Ostschweiz & St. Gallen Medical School, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland  \nAI  \nCAPNON  \nCT  \nIDEM  \nHU  \nMRI  \nOPLL  \nOR  \nROI  \nT1w-MGE  \nTE  \nTR  \nsCT  \nArtificial intelligence  \nCalcifying pseudoneoplasms of the neuraxis Computed tomography  \nIntradural extramedullary tumor of the spine Hounsfield units  \nMagnetic resonance imaging  \nOssification of the posterior longitudinal ligament  \nOdds ratio  \nRegion of interest  \nT1-weighted multiple gradient echo  \nEcho time  \nRepetition time  \nSynthetic CT  \nSD Standard deviation  \nSWI Susceptibility-weighted imaging  \nIntroduction  \nIntradural extramedullary tumors ofthe spine (IDEMs) constitute a group of usually benign neoplasms, which require surgical resection if symptomatic and/or progressive in size [1, 6, 35]. Treatment is typically perfor","cbCaigZN4RTOdoUE","https://ap.wps.com/l/cbCaigZN4RTOdoUE","pdf",1203906,"English","# Abstract\n## Purpose\n## Methods\n## Results\n## Conclusions\n# Introduction","[{\"question\":\"What clinical problem does the study address for intradural spinal tumors?\",\"answer\":\"The study targets the need to assess the degree of calcification to support surgical planning and decision-making for intradural lesions.\"},{\"question\":\"How was BoneMRI validated in the study?\",\"answer\":\"A prospective observational cohort compared conventional CT and MRI-derived synthetic CT generated by BoneMRI, with a post-hoc focus on patients with intradural tumors.\"},{\"question\":\"What were the key findings regarding visualization of calcified intradural tumors?\",\"answer\":\"Conventional CT showed all selected tumors, including densely calcified ones, while synthetic CT detected none, with tumor dimensions measured as 0 mm in both axial and sagittal planes.\"}]","Evaluation of Magnetic Resonance Imaging and Deep Learning-Based Synthetic Computed Tomography for Calcified Intradural Tumors | PDF",1790713095,23]