title: Combined PET/MR imaging in neurology: MR-based attenuation correction implies a strong spatial bias when ignoring bone.
abstract: OBJECTIVE
  Combined PET/MR systems have now become available for clinical use. Given the lack of integrated standard transmission (TX) sources in these systems, attenuation and scatter correction (AC) must be performed using the available MR-images. Since bone tissue cannot easily be accounted for during MR-AC, PET quantification can be biased, in particular, in the vicinity of the skull. Here, we assess PET quantification in PET/MR imaging of patients using phantoms and patient data.
  
  
  METHODS
  Nineteen patients referred to our clinic for a PET/CT exam as part of the diagnostic evaluation of suspected dementia were included in our study. The patients were injected with 200MBq [(18)F]FDG and imaged with PET/CT and PET/MR in random sequence within 1h. Both, PET/CT and PET/MR were performed as single-bed acquisitions without contrast administration. PET/CT and PET/MR data were reconstructed following CT-based and MR-based AC, respectively. MR-AC was performed based on: (A) standard Dixon-Water-Fat segmentation (DWFS), (B) DWFS with co-registered and segmented CT bone values superimposed, and (C) with co-registered full CT-based attenuation image. All PET images were reconstructed using AW-OSEM, with neither resolution recovery nor time-of-flight option employed. PET/CT (D) or PET/MR (A-C) images were decay-corrected to the start time of the first examination. PET images following AC were evaluated visually and quantitatively using 10 homeomorphic regions of interest drawn on a transaxial T1w-MR image traversing the central basal ganglia. We report the relative difference (%) of the mean ROI values for (A)-(C) in reference to PET/CT (D). In a separate phantom experiment a 2L plastic bottle was layered with approximately 12mm of Gypsum plaster to mimic skull bone. The phantom was imaged on PET/CT only and standard MR-AC was performed by replacing hyperdense CT attenuation values corresponding to bone (plaster) with attenuation values of water. PET image reconstruction was performed with CT-AC (D) and CT-AC using the modified CT images corresponding to MR-AC using DWFS (A).
  
  
  RESULTS
  PET activity values in patients following MR-AC (A) showed a substantial radial dependency when compared to PET/CT. In all patients cortical PET activity was lower than the activity in the central region of the brain (10-15%). When adding bone attenuation values to standard MR-AC (B and C) the radial gradient of PET activity values was removed. Further evaluation of PET/MR activity following MR-AC (A) relative to MR-AC (C) using the full CT for attenuation correction showed an underestimation of 25% in the cortical regions and 5-10% in the central regions of the brain. Observations in patients were replicated by observations from the phantom study.
  
  
  CONCLUSIONS
  Our phantom and patient data demonstrate a spatially varying bias of the PET activity in PET/MR images of the brain when bone tissue is not accounted for during attenuation correction. This has immediate implications for PET/MR imaging of the brain. Therefore, refinements to existing MR-AC methods or alternative strategies need to be found prior to adopting PET/MR imaging of the brain in clinical routine and research.
authors.affiliation: Dept. of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. Electronic address: fling@pet.rh.dk.
authors.forename: Flemming Littrup
authors.initials: FL
authors.lastname: Andersen
authors.forename: Claes Nøhr
authors.initials: CN
authors.lastname: Ladefoged
authors.forename: Thomas
authors.initials: T
authors.lastname: Beyer
authors.forename: Sune Høgild
authors.initials: SH
authors.lastname: Keller
authors.forename: Adam Espe
authors.initials: AE
authors.lastname: Hansen
authors.forename: Liselotte
authors.initials: L
authors.lastname: Højgaard
authors.forename: Andreas
authors.initials: A
authors.lastname: Kjær
authors.forename: Ian
authors.initials: I
authors.lastname: Law
authors.forename: Søren
authors.initials: S
authors.lastname: Holm
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016477:Artifacts; D001921:Brain / Q000000981:diagnostic imaging* / Q000473:pathology*; D003704:Dementia / Q000175:diagnosis; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging / Q000379:methods; D049268:Positron-Emission Tomography / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012886:Skull / Q000000981:diagnostic imaging* / Q000473:pathology*
keywords: Attenuation correction; Image reconstruction; Neurology; PET/MR; Positron Emission Tomography