Does Q.Clear Processing Change PET Ratios? Quantitative Evidence Using BTXBrain-DAT

Introduction: Bayesian penalized likelihood (BPL) reconstruction algorithms, commercially implemented as Q.Clear (GE Healthcare), enhance image quality but may alter quantitative metrics. The impact of BPL on dopamine transporter (DAT) PET quantification, including ratios, remains unclear. This study investigates whether Q.Clear processing alters key metrics such as specific binding ratios (SBRs) and interregional ratios. Methods: We retrospectively analyzed 170 paired F-18 FP-CIT PET datasets reconstructed with conventional 3D-OSEM (baseline-DICOM) and Q.Clear (Q.Clear-DICOM). Quantification was performed using BTXBrain-DAT (Brightonix Imaging), yielding 57 specific binding ratios (SBRs), three asymmetry indices, and nine interregional ratios. Paired statistical tests, Bland-Altman plots, and reproducibility checks were conducted. Visual reads by two nuclear medicine physicians were also compared between datasets. Results: Q.Clear processing significantly altered all quantitative metrics (p < 0.001). SBR values changed in all 57 regions, with most high-uptake regions showing an increase and low-uptake regions showing a decrease. Striatal and caudate asymmetry indices showed significant differences (p < 0.0001), whereas the putamen index remained stable. All interregional ratios differed significantly, although Bland-Altman analysis indicated relative stability for ratios compared with asymmetric indices. BTXBrain-DAT showed perfect reproducibility on repeat analysis, and visual interpretation was unaffected by reconstruction method. Conclusions: Q.Clear (BPL) reconstruction substantially influences F-18 FP-CIT PET quantification, including ratios and asymmetry indices, while leaving visual interpretation unchanged. These findings highlight the need for caution when using image enhancement functions for quantitative analysis, particularly in clinical studies involving low-uptake regions or multicenter data comparisons.