BackgroundSkull base invasion in nasopharyngeal carcinoma (NPC) was shown to be a poor negative prognostic factor, and dual-energy CT (DECT) has heralded a new approach to detect this condition. The study aims to evaluate the value of DECT for detection of skull base invasion in NPC and compare the diagnostic performance of DECT with those of simulated single-energy CT (SECT) and MRI.MethodsThe imaging findings of 50 NPC patients and 31 participants in control group which underwent DECT examinations were assessed in this retrospective study. The skull base invasions were evaluated using 5-point scale by two blind observers. ROC analysis, Mcnemar test, paired t test, weightedKstatistics and intraclass correlation coefficient were performed to evaluate the diagnostic performance of simulated SECT, MRI and DECT.ResultsQuantitative analysis of DECT parameters showed higher normalized iodine concentration and effective atomic number values in sclerosis and lower values in erosion than those in normal bones (bothp< 0.05). Compared with simulated SECT and MRI, the diagnostic sensitivity for DECT was significantly improved from 75% (simulated SECT) and 84.26% (MRI) to 90.74% (DECT) (bothp< 0.001), specificity from 93.23% and 93.75% to 95.31 (bothp< 0.001), accuracy from 86.67% and 90.33% to 93.67%, and AUC from 0.927 and 0.955 to 0.972 (bothp< 0.05), respectively.ConclusionsDECT demonstrates better diagnostic performance than simulated SECT and MRI for detecting skull base invasions in NPC, even those slight bone invasions in early stage, with higher sensitivity, specificity and accuracy.Graphical Abstract