Nested Attention Network for Robust Medical Image Segmentation Under Digital Watermarking

Digital watermarking is widely used to protect medical images in terms of ownership, authenticity, and traceability; however, the embedding process may introduce subtle modifications that can affect the reliability of deep-learning-based clinical analysis. Existing studies have shown that watermarking has a negligible effect on medical image classification; nevertheless, its impact on segmentation performance remains insufficiently explored. Therefore, this paper aims to investigate the effects of segmentation model enhancement on watermarked medical image analysis. In this context, three representative watermarking approaches were employed, and five baseline segmentation models, namely U-Net, ResUNet++, SegNet, FCDenseNet, and TernausNet, were evaluated on two benchmark datasets: LIDC-IDRI and BRISC. Additionally, a novel deep learning model with nested attention mechanisms was specifically designed to improve feature extraction and increase sensitivity to subtle pixel-level variations in watermarked images. Segmentation performance was assessed using five standard evaluation metrics, including mean Intersection over Union (mIoU), Dice Similarity Coefficient (DSC), and the 95th percentile Hausdorff Distance (HD95). The experimental results indicate consistently minor performance degradation across both datasets. For the BRISC dataset, the reduction in mIoU ranges from 0.15% to 0.44%, while for the LIDC-IDRI dataset, it ranges from 0.19% to 0.29% compared with the no-watermarking baseline. These findings provide quantitative insight into the compatibility of watermarking techniques for medical image protection with AI-based medical image segmentation systems, highlighting their potential for broader clinical application.