This month, we are proud to celebrate the radiosurgery team at Prince of Wales Hospital in Randwick, Australia, for transforming the arteriovenous malformation (AVM) care they provide. They’ve done this by adopting frameless radiosurgery with digital subtraction angiography (DSA), enabled by Brainlab Elements Image Fusion Angio and Elements SmartBrush Angio.

Having now treated over 100 AVM patients using this dedicated workflow, the team recognizes both the departmental impact and scalability of this innovative approach in routine practice.

The challenge: Complex targets, logistical constraints. An AVM is an abnormal tangle of blood vessels for which radiosurgery can be a treatment option for select patients. Historically, AVM radiosurgery has relied on rigid immobilization with stereotactic head frames for accurate patient positioning and co-registration of multiple imaging studies, including 2D DSA and 3D image scans.

This traditional, frame-based process can lead to:

• Patient discomfort from invasive frame placement and wearing a frame throughout a full treatment day
• Logistical demands for the clinical team to schedule different imaging modalities with subsequent treatment planning and delivery the same day
• Repeat invasive angiography for treatment planning purposes

The innovation: Frameless treatments for AVM that incorporate DSA imaging. In a first for Australia, the team implemented Brainlab Elements solutions for angiography/DSA, a frameless approach for planning AVM treatments. With Elements Image Fusion Angio, multiple 2D DSA images can be co-registered using cerebrovascular structures with 3D planning CT or MR images. Clinicians can thereby simultaneously outline vascular targets in 2D and 3D datasets. The software also supports diagnostic 2D DSA images without requiring an additional frame-based angiography procedure.

This workflow enables:

• AVM contouring using multiple imaging modalities, including 2D DSA to improve visualization and spatial resolution of the nidus
• A more flexible schedule for imaging sessions
• Use of diagnostic 2D DSA which can omit the need for additional invasive procedures on the day of treatment

In their words: “For our most complex cases, this technology allows us to utilise catheter cerebral angiograms from different angles and switch between DSA and CT or MRI to precisely define the AVM nidus. The seamless switching between imaging modalities, and the ability to see volume adjustments instantly, has fostered a new level of confidence and standard of collaboration between our neuroradiology and radiation oncology colleagues and ensures we are delivering the most accurate plan possible.” – Andrew Cheung, Head of Department Interventional Neuroradiology, Prince of Wales Hospital

Why it matters. This shift isn’t just about better technology—it’s about a better experience. The team has created what they describe as: “a streamlined, frameless workflow while improving:

• Patient comfort
• Staff efficiency
• Treatment timelines and resource use”

Please join us in congratulating the Prince of Wales Hospital Radiosurgery Team, and in recognizing how innovation—when paired with dedication—can change what’s possible for complex AVM care.

*The statements made by the clinician represent their personal opinion and experience. These statements may not be supported by scientific evidence or peer-reviewed research. For verified information about the device, please refer to the manufacturer's official documentation.