First Arteriovenous Malformation Radiosurgery with New Brainlab Software

Treatment of cranial arteriovenous malformations (AVM) is complex and challenging due to the difficulty in differentiating the AVM nidus from related arteries and veins. Brainlab’s new Elements SmartBrush® Angio system uses sophisticated imaging software to facilitate the process. It has now been used clinically for the first time in an Irish Hospital.


Brainlab’s new Elements SmartBrush® Angio enables a direct correlation between diagnostic data sets containing temporal and, respectively spatial, information for a comprehensive definition of a patient’s cranial arteriovenous malformation (AVM) nidus. It allows clinicians to combine the unique insights gained from planar digital subtraction angiogram (DSA) images with the spatial information gained from volumetric imaging data sets. With this data, clinicians are able to clearly distinguish arteries and veins from the nidus, reducing the final target size and thereby enabling targeted stereotactic radiosurgery to the AVM nidus with protection of the surrounding healthy tissue. Color-coding of the blood flow facilitates in-depth interpretation of the 2D angiograms and is expected to further improve detailed differentiation of the nidus and the surrounding brain tissue. The Brainlab proprietary algorithm co-registers a 3D angiography data set to the un-localized 2D image sequence. The new fusion matches the anatomical vessel trees in both modalities. This end-to-end frameless setup effectively eliminates the need for localizer hardware.

The first patient was treated at St. Luke’s Radiation Oncology Centre at Beaumont Hospital in Dublin (SLROC at Beaumont), Ireland. Physicians used the system to plan and deliver a frameless radiosurgery treatment to a 30-year-old male patient who was experiencing seizures due to a mesial temporal AVM involving the hippocampus and abutting the midbrain. The efficiency of the process enabled the operators to correlate multiple imaging modalities, identify the AVM nidus by incorporating the diverse information captured by each individual modality and facilitate shielding for connecting arteries and veins during subsequent treatment planning.

Establishing a direct link between the various data sets is designed to eliminate both the need for repeat angiography on the day of treatment and the requirement for patient fixation with an invasive head-ring. This benefits patients and caregivers alike as it permits utilization of diagnostic angiography data for treatment planning and unlocks the potential of frameless radiosurgery.

 Physician comments

“With SmartBrush Angio we can deliver highly sophisticated frameless radiosurgical treatment of brain AVMs,” explained Seyed Mohsen Javadpour, MD, Neurosurgeon and Clinical Senior Lecturer at Beaumont Hospital in Dublin. “In particular, this software eliminates the need for additional planning digital subtraction angiography (DSA) for nidus identification as it allows us to fuse the pre-existing diagnostic DSA with volumetric MRI and CT images. Therefore our patients avoid the discomfort and risks associated with invasive catheter cerebral angiography (such as stroke), receiving an overall highly sophisticated treatment. We will use SmartBrush Angio for all patients with cerebral AVMs undergoing stereotactic radiosurgery. Beyond radiosurgery, we see great promise with the use of this software for surgical planning in patients undergoing image-guided resection of brain AVMs. Fusion of multiple imaging modalities is easy with this software and it makes radiosurgical and surgical planning for AVMs more accurate.”

“SmartBrush Angio offers multiple, critical benefits to our hospital,” said David Fitzpatrick, MD, Radiation Oncologist, SLROC at Beaumont Hospital, Dublin, Ireland. “For clinicians, we can quickly complete the volumetric assessment of the AVM nidus with SmartBrush Angio. The software allows for dynamic use of existing diagnostic DSA images for enhanced visualization and identification of the AVM nidus during radiosurgery planning. By having the ability to use pre-existing DSA images, the hospital has the potential to save both bed days and costs.”

Company comments

“The Elements SmartBrush Angio software effectively articulates the Brainlab vision of indication-specific and highly automated software applications aimed at transforming practice patterns in radiosurgery,” said Stefan Vilsmeier, CEO and Founder, Brainlab. “We are continuously building on our 25 years of experience in rethinking radiosurgery and this is one of many more innovations to come.”

Source: Brainlab, Inc., Business Wire

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