Background Non-invasive presurgical diagnosis of brain tumor types from Magnetic Resonance Imaging (MRI) is essential but challenging due to overlapping imaging features across tumor types, inter-observer variability, and the extensive training required for expertise. We aimed to develop an MRI-based Artificial Intelligence (AI) model for automatic and reliable brain tumor classification with diagnostic uncertainty quantification and radiology reports generation. Methods We developed BrainVLM to classify all 12 World Health Organization (WHO) 2021 brain tumor types. BrainVLM integrates an uncertainty quantification strategy to indicate prediction reliability and a module for generating radiology reports to elucidate the clinical rationale. BrainVLM was trained on multi-modal data (MRI scans, demographics, and radiology reports) from 40,043 individuals. It was validated on 5,211 patients with pathologically confirmed brain tumors, including 3,877 held-out patients from the primary hospital and 1,334 patients from 11 independent hospitals. We further conducted two proof-of-concept studies to validate its clinical utility in AI-clinician workflows: 1) a blinded multi-reader study where 12 neuroradiologists across varying experience levels interpreted 248 retrospective cases with or without AI assistance, and 2) a real-world prospective study in which 1,009 patients were independently and blindly assessed by BrainVLM and radiologists before surgery. Additionally, we demonstrated BrainVLM's utility in preoperative molecular subgroup prediction for adult-type diffuse gliomas, using a multi-center cohort of 632 patients.

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