[Prospects and future: evolution of stereotactic methodology for planning]

Area of Science:

• Neurosurgery
• Radiosurgery
• Medical Imaging

Background:

• The Talairach stereotactic methodology has been utilized for Linac radiosurgery of cerebral arteriovenous malformations (AVMs) since 1984.
• Integration of CT and MR images into stereotactic space has enhanced precision.
• Stereotactic angiography remains the primary method for defining AVM targets.

Purpose of the Study:

• To evaluate the evolution and future directions of stereotactic radiosurgery for cerebral AVMs.
• To highlight the role of advanced imaging techniques in improving target definition and treatment planning.
• To discuss the transition from frame-based to frameless radiosurgery systems.

Main Methods:

• Utilizing stereotactic angiography for target definition in cerebral AVMs.
• Combining multimodal imaging (CT, MR, angiography) oriented into stereotactic space for improved 3D visualization.
• Exploring frameless radiosurgery with real-time tracking (e.g., CyberKnife) and integrated mobile fluoroscopy.

Main Results:

• Multimodal imaging, particularly CT-angiography and MR-angiography, offers superior definition of AVM tridimensional configuration compared to stereotactic angiography alone.
• Frameless radiosurgery with real-time tracking is poised to replace invasive frame-based procedures.
• Mobile, short-distance fluoroscopic systems integrated into surgical workstations will supersede long-distance fixed X-ray equipment.

Conclusions:

• Advanced imaging techniques are crucial for precise targeting in radiosurgery of cerebral AVMs.
• The future of AVM radiosurgery involves frameless, image-guided approaches with enhanced real-time tracking.
• CT and MR-angiography are increasingly replacing conventional angiography for AVM identification, reserving DSA for complex cases.