Positron emission tomography/computed tomography--imaging protocols, artifacts, and pitfalls

There has been a longstanding interest in fused images of anatomical information, such as that provided by computed tomography (CT) or magnetic resonance imaging (MRI) systems, with biological information obtainable by positron emission tomography (PET). The near-simultaneous data acquisition in a fixed combination of a PET and a CT scanner in a combined PET/CT imaging system minimizes spatial and temporal mismatches between the modalities by eliminating the need to move the patient in between exams. In addition, using the fast CT scan for PET attenuation correction, the duration of the examination is significantly reduced compared to standalone PET imaging with standard rod-transmission sources. The main source of artifacts arises from the use of the CT-data for scatter and attenuation correction of the PET images. Today, CT reconstruction algorithms cannot account for the presence of metal implants, such as dental fillings or prostheses, properly, thus resulting in streak artifacts, which are propagated into the PET image by the attenuation correction. The transformation of attenuation coefficients at X-ray energies to those at 511 keV works well for soft tissues, bone, and air, but again is insufficient for dense CT contrast agents, such as iodine or barium. Finally, mismatches, for example, due to uncoordinated respiration result in incorrect attenuation-corrected PET images. These artifacts, however, can be minimized or avoided prospectively by careful acquisition protocol considerations. In doubt, the uncorrected images almost always allow discrimination between true and artificial finding. PET/CT has to be integrated into the diagnostic workflow for harvesting the full potential of the new modality. In particular, the diagnostic power of both, the CT and the PET within the combination must not be underestimated. By combining multiple diagnostic studies within a single examination, significant logistic advantages can be expected if the combined PET/CT examination is to replace separate state-of-the-art PET and CT exams, thus resulting in significantly accelerated diagnostics.