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Frequent Diagnostic Errors in Cardiac PET/CT Due to Misregistration of CT Attenuation and Emission PET Images: A Definitive Analysis of Causes, Consequences, and Corrections

¹ The Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School and Memorial Hermann Hospital, Houston, Texas; ² Imaging Physics Department, M.D. Anderson Cancer Center, University of Texas, Houston, Texas; ³ The Weatherhead PET Center and Division of Cardiology, The Department of Medicine, University of Texas Medical School at Houston, Houston, Texas; ⁴ Cardiology Division, Department of Medicine, Northwestern Medical School, Chicago, Illinois; ⁵ Department of Medicine, University of Texas Medical School at Houston, Houston, Texas; and ⁶ The Weatherhead PET Center and Division of Cardiology, Department of Medicine, University of Texas Medical School at Houston, Houston, Texas

View larger version (66K): [in this window] [in a new window]   FIGURE 1.  (A) Topographic 3D displays of helical CT PET with a mild-to-moderate anterior and lateral defect (top row) that is not present on cine CT PET (bottom row). White indicates the highest myocardial uptake of 82Rb, reflecting the highest myocardial perfusion, with red being the next highest and progressively lower perfusion indicated by color gradations from red to yellow, green, and blue. (B) For same patient as in A, misregistration on helical CT-PET fusion images in transaxial (top) and coronal (bottom) views. Arrows indicate heart borders on helical CT and PET emission images as unmatched, with region of misregistration corresponding to area of artifactual defect. Magnified inset illustrates quantification of misregistration in transaxial view—here, 12 mm—using an electronic caliper on the screen. (C) For same patient, cine CT-PET fusion images show good coregistration associated with no defect and a normal scan.

View larger version (90K): [in this window] [in a new window]   FIGURE 2.  (A) Topographic 3D displays of helical CT PET with severe anterior, apical, lateral, and basal inferior defects (top row) that are also present but less severe on cine CT PET (middle row). Anterior, apical, and lateral defects normalize on shifted cine CT PET (bottom row). (B) For same patient as in A, helical CT-PET fusion images in transaxial (top) and coronal (bottom) views show marked misregistration. Arrows indicate heart borders on helical CT and PET emission images as unmatched, with region of misregistration corresponding to area of artifactual defect. (C) For same patient, cine CT-PET fusion images also show misregistration. (D) For same patient, shifted cine CT-PET fusion images with no misregistration associated with disappearance of artifactual anterior, apical, and lateral artifactual defects.

View larger version (72K): [in this window] [in a new window]   FIGURE 3.  (A) Stress perfusion images at yearly intervals using a Positron PET scanner with rotating rod transmission source show progressive improvement on a strict lifestyle and medical regimen. (B) For same patient as in A, rest and stress helical CT-PET fusion images at follow-up in 2006 were acquired during normal breathing before cine CT was available. Diaphragm–heart mismatch (arrows) on stress fusion image caused attenuation overcorrection inferiorly and associated relative anterior defect on stress PET despite borders of heart being properly coregistered on both rest and stress perfusion images (see text). (C) For same patient, follow-up stress perfusion helical CT PET images in 2006. Diaphragm–heart mismatch on stress fusion image shown in B caused artifactual anterior, lateral, and inferoapical defects (top row) that disappeared on repeated stress scan using Positron PET scanner with a rotating rod attenuation transmission source (bottom row) and correct coregistration.

View larger version (57K): [in this window] [in a new window]   FIGURE 4.  (A) Resting CT transmission image acquired over 29 s with normal breathing shows "motion layering" of CT scan (top row). Helical CT-PET fusion image demonstrates a corresponding notching of attenuation (arrows) and notched undercorrection of PET data. (B) For same patient as in A, corresponding rest–stress 3D topographic display has linear anterior and lateral artifacts (arrows) on rest emission scan caused by motion layering on resting CT scan, not present on stress scan. Mild inferior defect is not associated with any misregistration but is due to diffuse atherosclerosis of posterior descending coronary artery.