Cited by 283Explainable Artificial Intelligence (XAI)Artificial Intelligence in Healthcare and EducationCOVID-19 diagnosis using AI

The DOI matches its Crossref record; 218 of the 315 references it cites were found in a registry or an index, and 1 are not checked yet; 4 of the 278 sources its claims cite were checked for support.

Survey of explainable artificial intelligence techniques for biomedical imaging with deep neural networks

Open access
Nazir, Sajid, Dickson, Diane M., Akram, Muhammad Usman·2023·Computers in Biology and Medicine

Abstract

Artificial Intelligence (AI) techniques of deep learning have revolutionized the disease diagnosis with their outstanding image classification performance. In spite of the outstanding results, the widespread adoption of these techniques in clinical practice is still taking place at a moderate pace. One of the major hindrance is that a trained Deep Neural Networks (DNN) model provides a prediction, but questions about why and how that prediction was made remain unanswered. This linkage is of utmost importance for the regulated healthcare domain to increase the trust in the automated diagnosis system by the practitioners, patients and other stakeholders. The application of deep learning for medical imaging has to be interpreted with caution due to the health and safety concerns similar to blame attribution in the case of an accident involving autonomous cars. The consequences of both a false positive and false negative cases are far reaching for patients' welfare and cannot be ignored. This is exacerbated by the fact that the state-of-the-art deep learning algorithms comprise of complex interconnected structures, millions of parameters, and a 'black box' nature, offering little understanding of their inner working unlike the traditional machine learning algorithms. Explainable AI (XAI) techniques help to understand model predictions which help develop trust in the system, accelerate the disease diagnosis, and meet adherence to regulatory requirements. This survey provides a comprehensive review of the promising field of XAI for biomedical imaging diagnostics. We also provide a categorization of the XAI techniques, discuss the open challenges, and provide future directions for XAI which would be of interest to clinicians, regulators and model developers.

Verified 2026-10-07 · 1 reference not checked yet

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This survey reviews explainable AI (XAI) techniques for deep neural network–based biomedical imaging, categorizing methods and mapping them to imaging modalities and medical specialties. It finds Grad-CAM is the most widely used XAI method, while evaluation standards, definitions, and clinical validation remain open challenges.

Key findings

  • The survey categorizes XAI techniques into visualization (perturbation-based and gradient/backpropagation-based) and explanation by example, further classified by scope (local/global), applicability (model-specific/model-agnostic), and usage (intrinsic/post hoc).
  • Across biomedical imaging, Grad-CAM is the most common and preferred XAI method, followed by LRP, LIME, and SHAP; use is increased in neurology, respiratory, and ophthalmic studies, with MRI dominant in neurology, CXR in respiratory, and fundus images in ophthalmology.
  • Reported modality-specific performance examples include COVID-19 CXR with EfficientNet-B7 at 95.01% accuracy and AUC 0.950; COVID-19 CT/CXR with VGG-19 at 95.61% accuracy; low-quality CT with ResNet-50 at 99.87% accuracy and 99.58% sensitivity; Parkinson’s disease 3D CNN at 95.29% accuracy and ROC-AUC 0.98; neonatal MRI brain dysmaturation at 98.5% accuracy; coronary CTA atherosclerosis AUC 0.91; and coronary artery calcium detection AUC 0.9627 with 0.9272 accuracy.
  • Evaluation of explainability remains unsettled: the paper states there is no agreement on measuring or evaluating explainability, and it reviews quantitative metrics such as deletion/insertion, CLEVR, and MSFI alongside qualitative human evaluation.

Methods

  • Literature survey; papers were selected by searching Web of Science, ScienceDirect, IEEE Explore, and Google Scholar for articles on explainable, interpretable, and trustworthy XAI techniques for biomedical applications.
  • No primary experiments or new data are reported; the paper synthesizes XAI techniques, tools/frameworks, evaluation methods, and applications grouped by imaging modality and medical specialty.
  • Techniques are categorized by scope, applicability, and usage/nature, with summaries provided in tables.

Limitations

  • Stated: there is no universally agreed definition of “explanation”; no agreement on evaluation metrics; lack of algorithm standardization; most explainability techniques are visualization-based and qualitative; current definitions lack consistency and may represent a false hope for patient-level decision support; model-highlighted features may differ from human-identified features.
  • Stated: the paper calls for inherently interpretable and accurate models, human-in-the-loop systems, regulatory benchmarks, and federated learning, implying these are not yet resolved.
  • Evident from the text: the survey does not report a systematic review protocol, search dates, inclusion/exclusion counts, or formal quality appraisal, and it does not independently validate the XAI methods it reviews.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.compbiomed.2023.106668

Cites

218 of 219 references verified0 citation errors · 0 not checkable

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Verification

Claims the paper makes

250 Not checked yet · 30 Own interpretation · 9 No basis given · 4 Own result · 3 Partly supported · 1 Supported · accuracy not yet measured

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Show all 137 claims

  • It may state two separate claims as one. 81
  • Probably not a substantial claim. 102
  • The quote only partly states this claim. 4
160 of 160
  • The paper relies on this without support.

    XAI techniques help to understand model predictions which help develop trust in the system, accelerate the disease diagnosis, and meet adherence to regulatory requirements.

    “Explainable AI (XAI) techniques help to understand model predictions which help develop trust in the system, accelerate the disease diagnosis, and meet adherence to regulatory requirements.”
  • The paper relies on this without support.

    There is often an explainability gap between the model's prediction and its explanations being understandable to a human.

    “However, there is often an explainability gap between the model's prediction and its explanations being understandable to a human.”
  • The paper relies on this without support.

    Incorporating explainability into a model takes time and effort, and may affect its prediction accuracy.

    “Incorporating explainability into a model takes time and effort, and may affect its prediction accuracy.”
  • The paper relies on this without support.

    The use of XAI techniques can reduce the workload of the clinicians, help to make better diagnosis, and reduce the complications associated with a false positive and a false negative outcome.

    “The use of XAI techniques can reduce the workload of the clinicians, help to make better diagnosis, and reduce the complications associated with a false positive and a false negative outcome.”
  • The paper relies on this without support.

    Medical practitioners are more likely to employ and trust a system if they can understand the reasoning of a prediction by a model.

    “They are more likely to employ and trust a system if they can understand the reasoning of a prediction by a model.”
  • The paper relies on this without support.

    Patients require assurance that the XAI methods can be trusted, and are providing a valid and consistent prediction.

    “Patients require assurance that the XAI methods can be trusted, and are providing a valid and consistent prediction.”
  • The paper relies on this without support.

    DNN can provide very accurate predictive performance but are hard to interpret or explain.

    “DNN can provide very accurate predictive performance but owing to a large number of trainable parameters, layers, and the performance determined through the hyperparameters, these are hard to interpret or explain.”
  • The paper relies on this without support.

    CXR is the most commonly used imaging modality for detecting COVID-19 or lung infections, but it is less accurate than CT.

    “CXR is the most commonly used imaging modality for detecting COVID-19, or lung infections, however, in comparison to CT, it is less accurate.”
  • The paper relies on this without support.

    MRI is the most favored imaging modality for neurology and is particularly useful for neurodegenerative diseases.

    “MRI is the most favored imaging modality for neurology and particularly useful for the neurodegenerative diseases.”
  • The paper relies on this without support.

    Ophthalmologists are interested in finding the parameters responsible for a specific finding, rather than just knowing the final diagnosis.

    “The ophthalmologists are interested in finding out the parameters responsible for a specific finding, rather than just knowing the final diagnosis.”
  • The paper relies on this without support.

    In fundus images, the actual variations in landmarks (blood vessels, optic disc, fovea/macula) along with appearances of any new lesion are important.

    “In fundus images, the actual variations in landmarks i.e. blood vessels, optic disc and fovea/macula region along with appearances of any new lesion are important.”
  • The paper relies on this without support.

    For OCT images, it is important to look into layer variants and lesions appearing in those layers.

    “For OCT images, it is important to look into layer variants and lesions appearing in those layers.”
  • The paper relies on this without support.

    The labelled datasets used to train DNNs are often from multiple sources or maintained by different organisations owning the data.

    “The labelled datasets used to train DNNs are often from multiple sources or maintained by different organisations owning the data.”
  • The paper relies on this without support.

    One of the stated advantages of DNN is automated learning of image features and overcoming problems associated with hand-crafted features.

    “One of the stated advantages of DNN is that of an automated learning of the image features and overcoming the problems associated with the hand-crafted features.”
  • The paper relies on this without support.

    Trained DNN models can provide predictions comparable to human experts in a fraction of the time.

    “The trained DNN model can provide predictions comparable to human expert in a fraction of the time”
  • The paper relies on this without support.

    DNN predictions comparable to human experts are not sufficient to fully delegate medical diagnosis to an algorithm.

    “however, this is not sufficient to fully delegate the medical diagnosis to an algorithm”
  • The paper relies on this without support.

    Human expertise cannot be dispensed, and only simple and time-consuming tasks should be directed to AI.

    “However, human expertise cannot be dispensed and only simple, and time-consuming tasks should be directed to AI.”
  • The paper relies on this without support.

    The ultimate beneficiary of model explainability is a human user.

    “The ultimate beneficiary of the model explainability is a human user.”
  • The paper relies on this without support.

    The final decision for image-based disease diagnosis would rest with the specialist, whereas XAI model insights should be used only to aid the decision.

    “Similar to the role of an autonomous car driver, the final decision for image-based disease diagnosis would rest with the specialist whereas the XAI model insights should be used only to aid the decision.”
  • The paper relies on this without support.

    Currently, image-based diagnosis and prognosis in biomedical imaging require expert opinion of practitioners who are already overburdened.

    “Currently, the image-based diagnosis and prognosis in the different disciplines of biomedical imaging such as radiology and ophthalmology require expert opinion of practitioners who are already overburdened.”
  • The paper relies on this without support.

    Increasingly, there are health and legal regulations that mandate approval and compliance for deep learning techniques.

    “Increasingly, there are health and legal regulations that mandate approval and compliance for the deep learning techniques which can be helped using XAI techniques.”
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Citations

Cites

Items 201–219 of 219

Research works printed but not linked: 10

  1. Durán, 2021, vol. 297
  2. A. Preece, D. Harborne, D. Braines, R. Tomsett and S. Chakraborty, “Stakeholders in Explainable AI,” [Online]. Available: https://doi.org/10.48550/arXiv.1810.00184. [Accessed 15 September 2022]. · DOI · Paper page
  3. V. Petsiuk, A. Das and K. Saenko, “RISE: Randomized Input Sampling for Explanation of Black-box Models,” [Online]. Available: https://doi.org/10.48550/arXiv.1806.07421. [Accessed 15 September 2022]. · DOI
  4. Adebayo, 2018, Sanity checks for saliency maps, Adv. Neural Inf. Process. Syst., 31
  5. Alber, 2019, iNNvestigate neural networks, J. Mach. Learn. Res., 20, 1
  6. Spinner, 2020, IEEE Trans. Visual. Comput. Graph., 26, 1064
  7. Panwar, 2020, vol. 140
  8. Liz, 2021, Ensembles of Convolutional Neural Network models for pediatric pneumonia diagnosis, Future Generat. Comput. Syst., 122, 220, 10.1016/j.future.2021.04.007 · DOI
  9. Kim, 2018, ICADx: interpretable computer aided diagnosis of breast masses, Medical Imaging 2018: Computer-Aided Diagnosis, 10575, 450
  10. Hampe, 2019, vol. 6

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Metadata

Authors
Nazir, S., Dickson, D. M., & Akram, M. U.
Affiliations
  • Glasgow Caledonian University (GB)
  • National University of Sciences and Technology (PK)
Corresponding author
Nazir, Sajid
Venue
Computers in Biology and Medicine
Publisher
Elsevier BV
Published
2023-04
Volume
156
Pages
106668
ISSN
0010-4825 (ISSN-L)
OpenAlex
W4321350922
Cited by
283
References
315
Citations by year
2026: 70 · 2025: 104 · 2024: 70 · 2023: 37
FWCI
5.83
Type
journal article
Language
en
Open access
Locations
  • Computers in Biology and Medicine (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • ResearchOnline (acceptedVersion, cc-by)
  • OSTI OAI (U.S. Department of Energy Office of Scientific and Technical Information) (submittedVersion)
  • ResearchOnline (Glasgow Caledonian University) (submittedVersion, cc-by)
Funders
  • Glasgow Caledonian University (10386)
  • Defense Advanced Research Projects Agency
  • Global Challenges Research Fund
  • Office of Defense Nuclear Nonproliferation
  • Alzheimer's Disease Neuroimaging Initiative
Topics
  • Physical Sciences › Computer Science › Artificial Intelligence › Explainable Artificial Intelligence (XAI)
  • Health Sciences › Medicine › Health Informatics › Artificial Intelligence in Healthcare and Education
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › COVID-19 diagnosis using AI
Keywords
explainable AI, biomedical imaging, deep neural network, medical image classification, diagnosis, model interpretability, regulatory compliance, black-box models
MeSH terms
Machine Learning, Algorithms, Artificial Intelligence, Diagnostic Imaging, Humans, Neural Networks, Computer

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