Image artifacts from MR-based attenuation correction in clinical, whole-body PET/MRI

Purpose

Integrated whole-body PET/MRI tomographs have become available. PET/MR imaging has the potential to supplement, or even replace combined PET/CT imaging in selected clinical indications. However, this is true only if methodological pitfalls and image artifacts arising from novel MR-based attenuation correction (MR-AC) are fully understood.

Results

Here we present PET/MR image artifacts following routine MR-AC, as most frequently observed in clinical operations of an integrated whole-body PET/MRI system.

Conclusion

A clinical adoption of integrated PET/MRI should entail the joint image display and interpretation of MR data, MR-based attenuation maps and uncorrected plus attenuation-corrected PET images in order to recognize potential pitfalls from MR-AC and to ensure clinically accurate image interpretation.     

Evaluation of an attenuation correction method for PET/MR imaging of the head based on substitute CT images

Object

The aim of this study was to evaluate MR-based attenuation correction of PET emission data of the head, based on a previously described technique that calculates substitute CT (sCT) images from a set of MR images.

Materials and methods

Images from eight patients, examined with ¹⁸F-FLT PET/CT and MRI, were included. sCT images were calculated and co-registered to the corresponding CT images, and transferred to the PET/CT scanner for reconstruction. The new reconstructions were then compared with the originals. The effect of replacing bone with soft tissue in the sCT-images was also evaluated.

Results

The average relative difference between the sCT-corrected PET images and the CT-corrected PET images was 1.6 % for the head and 1.9 % for the brain. The average standard deviations of the relative differences within the head were relatively high, at 13.2 %, primarily because of large differences in the nasal septa region. For the brain, the average standard deviation was lower, 4.1 %. The global average difference in the head when replacing bone with soft tissue was 11 %.

Conclusion

The method presented here has a high rate of accuracy, but high-precision quantitative imaging of the nasal septa region is not possible at the moment.     

PET/MRI in cancer patients: first experiences and vision from Copenhagen

Combined PET/MRI systems are now commercially available and are expected to change the medical imaging field by providing combined anato-metabolic image information. We believe this will be of particular relevance in imaging of cancer patients. At the Department of Clinical Physiology, Nuclear Medicine & PET at Rigshospitalet in Copenhagen we installed an integrated PET/MRI in December 2011. Here, we describe our first clinical PET/MR cases and discuss some of the areas within oncology where we envision promising future application of integrated PET/MR imaging in clinical routine. Cases described include brain tumors, pediatric oncology as well as lung, abdominal and pelvic cancer. In general the cases show that PET/MRI performs well in all these types of cancer when compared to PET/CT. However, future large-scale clinical studies are needed to establish when to use PET/MRI. We envision that PET/MRI in oncology will prove to become a valuable addition to PET/CT in diagnosing, tailoring and monitoring cancer therapy in selected patient populations.     

A systematic review on the use of quantitative imaging to detect cancer therapy adverse effects in normal-appearing brain tissue

Cancer therapy for both central nervous system (CNS) and non-CNS tumors has been previously associated with transient and long-term cognitive deterioration, commonly referred to as ‘chemo fog’. This therapy-related damage to otherwise normal-appearing brain tissue is reported using post-mortem neuropathological analysis. Although the literature on monitoring therapy effects on structural magnetic resonance imaging (MRI) is well established, such macroscopic structural changes appear relatively late and irreversible. Early quantitative MRI biomarkers of therapy-induced damage would potentially permit taking these treatment side effects into account, paving the way towards a more personalized treatment planning.

This systematic review (PROSPERO number 224196) provides an overview of quantitative tomographic imaging methods, potentially identifying the adverse side effects of cancer therapy in normal-appearing brain tissue. Seventy studies were obtained from the MEDLINE and Web of Science databases. Studies reporting changes in normal-appearing brain tissue using MRI, PET, or SPECT quantitative biomarkers, related to radio-, chemo-, immuno-, or hormone therapy for any kind of solid, cystic, or liquid tumor were included. The main findings of the reviewed studies were summarized, providing also the risk of bias of each study assessed using a modified QUADAS-2 tool. For each imaging method, this review provides the methodological background, and the benefits and shortcomings of each method from the imaging perspective. Finally, a set of recommendations is proposed to support future research.

     

ESMRMB 2013, 30th Annual Scientific Meeting,Toulouse, France, 3-5 October: Abstracts,Thursday

After the very successful clinical introduction of combined PET/CT imaging a decade ago, a hardware combination of PET and MR is following suit. Today, three different approaches towards integrated PET/MR have been proposed: (1) a triple-modality system with a 3T MRI and a time-of-flight PET/CT installed in adjacent rooms, (2) a tandem system with a 3T MRI and a time-of-flight PET/CT in a co-planar installation with a joint patient handling system, and (3) a fully-integrated system with a whole-body PET system mounted inside a 3T MRI system. This special issue of MAGMA brings together contributions from key experts in the field of PET/MR, PET/CT and CT. The various papers share the author’s perspectives on the state-of-the-art PET/MR imaging with any of the three approaches mentioned above. In addition to several reviews discussing advantages and challenges of combining PET and MRI for clinical diagnostics, first clinical data are also presented. We expect this special issue to nurture future improvements in hardware, clinical protocols, and efficient post-processing strategies to further assess the diagnostic value of combined PET/MR imaging. It remains to be seen whether a so-called “killer application” for PET/MRI will surface. In that case PET/MR is likely to excel in pre-clinical and selected research applications for now. This special issue helps the readers to stay on track of this exciting development.     

Feasibility of diffusion-weighted imaging with DWIBS in staging Hodgkin lymphoma in pediatric patients: comparison with PET/CT

Objective

The aim of the study was to evaluate feasibility of diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) method in diagnosing Hodgkin lymphoma in pediatric patients and to compare it with 18F-FDG PET/CT as a gold standard.

Materials and methods

Eleven patients (median age 14) with newly diagnosed Hodgkin lymphoma were examined with 18F-FDG PET/CT and MRI including whole-body DWIBS sequence (b = 0, 800 s/mm²), before the oncologic treatment. About 26 locations of lymphatic tissues were evaluated visually and quantitatively using ADC_mean (DWIBS) and SUV_max (18F-FDG PET/CT), respectively.

Results

All affected lymph node regions (n = 134) diagnosed in 18F-FDG PET/CT were found with DWIBS, presenting decreased diffusion. Significant correlation was found between ADC and SUV values (R² = − 0.37; p = 0.0001). Nevertheless, additional 33 regions were recognized only by DWIBS. They were significantly smaller than regions diagnosed by both methods.

Discussion

Agreement between DWIBS and 18F-FDG PET/CT for detection and staging of malignant lymphoma is high. DWIBS can be used for the evaluation of pediatric Hodgkin lymphoma.

     

PET–MR imaging using a tri-modality PET/CT–MR system with a dedicated shuttle in clinical routine

Tri-modality PET/CT–MRI includes the transfer of the patient on a dedicated shuttle from one system into the other. Advantages of this system include a true CT-based attenuation correction, reliable PET-quantification and higher flexibility in patient throughput on both systems. Comparative studies of PET/MRI versus PET/CT are readily accomplished without repeated PET with a different PET scanner at a different time point. Additionally, there is a higher imaging flexibility based on the availability of three imaging modalities, which can be combined for the characterization of the disease. The downside is a somewhat higher radiation dose of up to 3 mSv with a low dose CT based on the CT-component, longer acquisition times and potential misalignment between the imaging components. Overall, the tri-modality PET/CT–MR system offers comparative studies using the three different imaging modalities in the same patient virtually at the same time, and may help to develop reliable attenuation algorithms at the same time.     

Physical and organizational provision for installation, regulatory requirements and implementation of a simultaneous hybrid PET/MR-imaging system in an integrated research and clinical setting

The implementation of hybrid imaging systems requires thorough and anticipatory planning at local and regional levels. For installation of combined positron emission and magnetic resonance imaging systems (PET/MRI), a number of physical and constructional provisions concerning shielding of electromagnetic fields (RF- and high-field) as well as handling of radionuclides have to be met, the latter of which includes shielding for the emitted 511 keV gamma rays. Based on our experiences with a SIEMENS Biograph mMR system, a step-by-step approach is required to allow a trouble-free installation. In this article, we present a proposal for a standardized step-by-step plan to accomplish the installation of a combined PET/MRI system. Moreover, guidelines for the smooth operation of combined PET/MRI in an integrated research and clinical setting will be proposed. Overall, the most important preconditions for the successful implementation of PET/MRI in an integrated research and clinical setting is the interdisciplinary target-oriented cooperation between nuclear medicine, radiology, and all referring and collaborating institutions at all levels of interaction (personnel, imaging protocols, reporting, selection of the data transfer and communication methods).     

Long-term sequestration of fluorinated compounds in tissues after fluvoxamine or fluoxetine treatment: a fluorine magnetic resonance spectroscopy study in vivo

Fluorine magnetic resonance spectroscopy (¹⁹F MRS), spectroscopic imaging (MRSI) and proton anatomical magnetic resonance imaging (¹H MRI) were performed on brains and lower extremities of six subjects in vivo concurrently with HPLC of serum to investigate tissue and plasma drug localization and withdrawal kinetics in humans treated with fluvoxamine or fluoxetine. ¹⁹F MRS signal was unexpectedly detected in the lower extremities months after complete disappearance of signal from plasma and brain. MRSI suggested that the lower extremity fluvoxamine signal originated mainly from bone marrow. Results suggest long-term sequestration of these drugs or their metabolites mainly in bone marrow and possibly in surrounding tissue and demonstrate the usefulness of MRS to reveal drug-trapping compartments in the body.     

Measurement techniques for magnetic resonance imaging of fast relaxing nuclei

In this review article, techniques for sodium (²³Na) magnetic resonance imaging (MRI) are presented. These techniques can also be used to image other nuclei with short relaxation times (e.g., ³⁹K, ³⁵Cl, ¹⁷O). Twisted projection imaging, density-adapted 3D projection reconstruction, and 3D cones are preferred because of uniform k-space sampling and ultra-short echo times. Sampling density weighted apodization can be applied if intrinsic filtering is desired. This approach leads to an increased signal-to-noise ratio compared to postfiltered acquisition in cases of short readout durations relative to T ₂ ^* relaxation time. Different MR approaches for anisotropic resolution are presented, which are important for imaging of thin structures such as myocardium, cartilage, and skin. The third part of this review article describes different methods to put more weighting either on the intracellular or the extracellular sodium signal by means of contrast agents, relaxation-weighted imaging, or multiple-quantum filtering.     

Approaches for the optimization of MR protocols in clinical hybrid PET/MRI studies

Magnetic resonance imaging (MRI) is the examination method of choice for the diagnosis of a variety of diseases. MRI allows us to obtain not only anatomical information but also identification of physiological and functional parameters such as networks in the brain and tumor cellularity, which plays an increasing role in oncologic imaging, as well as blood flow and tissue perfusion. However, in many cases such as in epilepsy, degenerative neurological diseases and oncological processes, additional metabolic and molecular information obtained by PET can provide essential complementary information for better diagnosis. The combined information obtained from MRI and PET acquired in a single imaging session allows a more accurate localization of pathological findings and better assessment of the underlying physiopathology, thus providing a more powerful diagnostic tool. Two hundred and twenty-one patients were scanned from April 2011 to January 2012 on a Philips Ingenuity TF PET/MRI system. The purpose of this review article is to provide an overview of the techniques used for the optimization of different protocols performed in our hospital by specialists in the following fields: neuroradiology, head and neck, breast, and prostate imaging. This paper also discusses the different problems encountered, such as the length of studies, motion artifacts, and accuracy of image fusion including physical and technical aspects, and the proposed solutions.     

MRI of ischemic lesions in gerbil brain

Brain temperature was varied during global forebrain ischemia in adult male Mongolian gerbils to produce a graded response to the ischemic insult. The severity of damage in the dorsal hippocampus was then quantified 4 days after the event withT ²-weighted 2DFT images and with histology. Statistically significant correlation was observed between magnetic resonance imaging (MRI) score and brain temperature and between MRI score and the area of the CA region in the dorsal hippocampus measured by histology.     

Radiotracers for positron emission tomography imaging

The use of positron emission tomography for clinical diagnostics has grown rapidly over the past 2 decades. This growth has mainly been due to advances in scanner technology, and particularly the introduction of the combined PET/CT scanner, and has been based almost exclusively on one PET radiopharmaceutical ([¹⁸F]fluorodeoxyglucose), which is broadly applicable to cancer patients. The availability of radiopharmaceuticals and the clinical diagnostic potential of PET has also supported the continued development of the scanner technology. Due to the efforts of many researchers worldwide in the field of radiopharmaceutical sciences, we are now seeing an increasing number of radiopharmaceuticals used for routine clinical diagnostic imaging. This article is intended as a short educational review, giving a brief overview of the design, preparation and use of PET radiopharmaceuticals, with some examples of highly clinically relevant PET tracers.     

Fluorine polymer probes for magnetic resonance imaging: quo vadis?

Over the last few years, the development and relevance of ¹⁹F magnetic resonance imaging (MRI) for use in clinical practice has emerged. MRI using fluorinated probes enables the achievement of a specific signal with high contrast in MRI images. However, to ensure sufficient sensitivity of ¹⁹F MRI, fluorine probes with a high content of chemically equivalent fluorine atoms are required. The majority of ¹⁹F MRI agents are perfluorocarbon emulsions, which have a broad range of applications in molecular imaging, although the content of fluorine atoms in these molecules is limited. In this review, we focus mainly on polymer probes that allow higher fluorine content and represent versatile platforms with properties tailorable to a plethora of biomedical in vivo applications. We discuss the chemical development, up to the first imaging applications, of these promising fluorine probes, including injectable polymers that form depots that are intended for possible use in cancer therapy.

     

In vivo diffusion tensor mapping of the brain of squirrel monkey, rat, and mouse using single-shot STEAM MRI

The purpose was to assess the potential of half Fourier diffusion-weighted single-shot STEAM MRI for diffusion tensor mapping of animal brain in vivo. A STEAM sequence with image acquisition times of about 500 ms was implemented at 2.35 T using six gradient orientations and b values of 200, 700, and 1200 s mm^–2. The use of half Fourier phase-encoding increased the signal-to-noise ratio by 45% relative to full Fourier acquisitions. Moreover, STEAM-derived maps of the relative anisotropy and main diffusion direction were completely free of susceptibility-induced signal losses and geometric distortions. Within measuring times of 3 h, the achieved resolution varied from 600×700×1000 m³ for squirrel monkeys to 140×280×720 m³ for mice. While in monkeys the accessible white matter fiber connections were comparable to those reported for humans, detectable fiber structures in mice focused on the corpus callosum, anterior commissure, and hippocampal fimbria. In conclusion diffusion-weighted single-shot STEAM MRI allows for in vivo diffusion tensor mapping of the brain of squirrel monkeys, rats, and mice without motion artifacts and susceptibility distortions.     

Direct cerebral and cardiac 17O-MRI at 3 Tesla: initial results at natural abundance

Purpose

To establish direct ¹⁷O-magnetic resonance imaging (MRI) for metabolic imaging at a clinical field strength of 3 T.

Methods

An experimental setup including a surface coil and transmit/receive switch was constructed. Natural abundance in vivo brain images of a volunteer were acquired with a radial three-dimensional (3D) sequence in the visual cortex and in the heart with electrocardiogram (ECG)-gating.

Results

In the brain, a signal-to-noise ratio of 36 was found at a nominal resolution of (5.6 mm)³, and a transverse relaxation time of T₂* = (1.9 ± 0.2) ms was obtained. In the heart ¹⁷O images were acquired with a temporal resolution of 200 ms.

Conclusion

Cerebral and cardiac ¹⁷O-MRI at natural abundance is feasible at 3 T.     

30 years of sodium/X-nuclei magnetic resonance imaging

In principle, all nuclei with nonzero spin can be employed for magnetic resonance imaging (MRI). Special scanner hardware and MR sequences are required to select the nucleus-specific frequency and to enable imaging with “sufficient” signal-to-noise ratio. This Special Issue starts with an overview of different nuclei that can be used for MRI today, followed by a review article about techniques required for imaging of quadrupolar nuclei with short relaxation times. Sequence developments to improve image quality and applications on different organs and diseases are presented for different nuclei (²³Na, ³⁵Cl, ¹⁷O, and ¹⁹F), with a focus on imaging at natural abundance.     

MRI of the lung using hyperpolarized <Superscript>3</Superscript>He at very low magnetic field (3 mT)

Optical pumping of ³He produces large (hyper) nuclear-spin polarizations independent of the magnetic resonance imaging (MRI) field strength. This allows lung MRI to be performed at reduced fields with many associated benefits, such as lower tissue susceptibility gradients and decreased power absorption rates. Here we present results of 2D imaging as well as accurate 1D gas diffusion mapping of the human lung using ³He at very low field (3 mT). Furthermore, measurements of transverse relaxation in zero applied gradient are shown to accurately track pulmonary O₂ partial pressure, opening the way for novel imaging sequences.     

Does PET/MR in human brain imaging provide optimal co-registration? A critical reflection

The introduction of hybrid positron emission/magnetic resonance tomography (PET/MR) in diagnostic clinical imaging was a major step in the evolution of ever-more sophisticated imaging systems combining two strategies formerly regarded as technically incompatible in a single device. The advent of PET/MR opened up many new avenues in clinical and research environments, mainly by providing multi-modality images obtained during a single examination. Ideally, simultaneous data acquisition with hybrid PET/MR should warrant exact image co-registration of all multi-modality image volumes provided by both systems. This assumes that there is negligible mutual electronic, technical and logistical interference on the respective simultaneous measurements. Recently, such hybrid dedicated head and whole-body systems were successfully applied in an increasing number of cases. When employed for brain imaging, PET/MR has the potential to provide high-resolution multi-modality datasets. However, it also demands careful consideration of the multitude of features offered, as well as the limitations. There are open issues that have to be considered, such as the handling of patient motion during extended periods of data acquisition, optimized sampling of derived images to ease the visual interpretation and quantitative evaluation of co-registered images. This paper will briefly summarize the current status of PET/MR within the framework of developments for image co-registration and discuss current limitations and future perspectives.     

Clinical assessment of myocardial viability using MRI during a constant infusion of Gd-DTPA

This study assessed the accuracy and feasibility of magnetic resonance imaging (MRI) during a constant infusion of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA) for the determination of myocardial viability in patients with recent acute myocardial infarction (AMI). Nine patients were studied within 10 days of AMI. Rest-redistribution²⁰¹Thallium (²⁰¹Tl) single photon emission computed tomography (SPECT) was used as a gold standard for viability. Using MRI, regional perfusion was assessed using dynamic imaging during a bolus injection of Gd-DTPA and viability was assessed during a continuous infusion. Finally, cine MR images were acquired at baseline, during low-dose dobutamine infusion and after recovery. To assess viability, the left ventricle was divided into 16 segments and signal intensity in corresponding MRI and redistribution SPECT segments were compared. Wall thickening index (WTI) was determined at each step during the dobutamine study. The results revealed that in five patients, reduced perfusion in infarcted regions was observed qualitatively during dynamic first pass imaging. There was a significant inverse correlation between²⁰¹Tl uptake and MRI signal intensity, i.e. infarcted tissue (low²⁰¹Tl uptake) had increased MR signal intensity. Segments were separated into normal (²⁰¹Tl uptake >90%) and infarcted (<60%). Infarcted MRI segments had greater signal intensity than normal segments (179±50 vs. 102±14%;P<0.0001). WTI in normal segments increased by 18±8.5% (P<0.0001) from baseline to 10 μg/kg per min of dobutamine while infarcted tissue WTI decreased 2.8±7.2% (P=0.17). Thus regions of myocardium that were infarcted as defined by reduced²⁰¹Tl uptake and absent contractile reserve showed greatly increased MRI signal intensity during a constant infusion of Gd-DTPA. The use of MRI during a constant infusion of Gd-DTPA is accurate and feasible for the determination of myocardial necrosis in a clinical setting.