Clinical Evaluation of Zero-Echo-Time Attenuation Correction for Brain ¹⁸F-FDG PET/MRI: Comparison with Atlas Attenuation Correction

Abstract

Accurate attenuation correction (AC) on PET/MR is still challenging. The purpose of this study was to evaluate the clinical feasibility of AC based on fast zero-echo-time (ZTE) MRI by comparing it with the default atlas-based AC on a clinical PET/MR scanner. <b>Methods:</b> We recruited 10 patients with malignant diseases not located on the brain. In all patients, a clinically indicated whole-body ¹⁸F-FDG PET/CT scan was acquired. In addition, a head PET/MR scan was obtained voluntarily. For each patient, 2 AC maps were generated from the MR images. One was atlas-AC, derived from T1-weighted liver acquisition with volume acceleration flex images (clinical standard). The other was ZTE-AC, derived from proton-density-weighted ZTE images by applying tissue segmentation and assigning continuous attenuation values to the bone. The AC map generated by PET/CT was used as a silver standard. On the basis of each AC map, PET images were reconstructed from identical raw data on the PET/MR scanner. All PET images were normalized to the SPM5 PET template. After that, these images were qualified visually and quantified in 67 volumes of interest (VOIs; automated anatomic labeling, atlas). Relative differences and absolute relative differences between PET images based on each AC were calculated. ¹⁸F-FDG uptake in all 670 VOIs and generalized merged VOIs were compared using a paired <i>t</i> test. <b>Results:</b> Qualitative analysis shows that ZTE-AC was robust to patient variability. Nevertheless, misclassification of air and bone in mastoid and nasal areas led to the overestimation of PET in the temporal lobe and cerebellum (%diff of ZTE-AC, 2.46% ± 1.19% and 3.31% ± 1.70%, respectively). The |%diff| of all 670 VOIs on ZTE was improved by approximately 25% compared with atlas-AC (ZTE-AC vs. atlas-AC, 1.77% ± 1.41% vs. 2.44% ± 1.63%, <i>P</i> &lt; 0.01). In 2 of 7 generalized VOIs, |%diff| on ZTE-AC was significantly smaller than atlas-AC (ZTE-AC vs. atlas-AC: insula and cingulate, 1.06% ± 0.67% vs. 2.22% ± 1.10%, <i>P</i> &lt; 0.01; central structure, 1.03% ± 0.99% vs. 2.54% ± 1.20%, <i>P</i> &lt; 0.05). <b>Conclusion:</b> The ZTE-AC could provide more accurate AC than clinical atlas-AC by improving the estimation of head–skull attenuation. The misclassification in mastoid and nasal areas must be addressed to prevent the overestimation of PET in regions near the skull base.