On the stability of Leksell Vantage stereotactic head frame fixation in Gamma Knife radiosurgery: a study based on cone-beam computed tomography imaging and the High Definition Motion Management system.

The authors' objective was to investigate the stability of the newly introduced Vantage stereotactic frame fixation in single-fraction Gamma Knife radiosurgery. A total of 255 patients were included in this work and treated with the Vantage frame and Leksell Gamma Knife (LGK) Icon equipped with cone-beam computed tomography (CBCT) imaging. After the frame was mounted on the patient's head, a CT scan was acquired. After the patient was positioned on the couch of LGK, CBCT was acquired to verify the target position before treatment delivery. A second CBCT examination was acquired after treatment delivery to assess intrafractional motion. During treatment delivery, the High Definition Motion Management (HDMM) system was enabled to track a marker on the nose tip of the patient as a surrogate of intracranial motion. The stability of the Vantage frame was deconstructed into two parts: 1) motion between CT and the first CBCT prior to treatment delivery (CT-CBCT1), and 2) motion between CBCT procedures during treatment delivery (CBCT1-CBCT2). Transformation between CT and CBCT1 was given by Leksell GammaPlan, whereas transformation between CBCT1 and CBCT2 required mathematical processing of the transformation and coregistration matrices in the source files. The average CT-CBCT1 displacement vector was 0.31 mm, with a range as great as 1.09 mm, and 89% and 97% of cases were within 0.5 mm and 0.7 mm, respectively. The CBCT1-CBCT2 displacement vectors averaged at 0.09 mm, with 97% of cases being within 0.2 mm. Spatial shift in the posterior direction was evident, with 94% of cases demonstrating this trend and averaging 0.05 mm. This was attributed to increased pressure on the posterior fixation pins. The HDMM displacement vectors presented larger values with an average of 0.4 mm and a range as great as 1.6 mm, and 98% of cases were within 1.0 mm. The correlation between CBCT1-CBCT2 and HDMM displacements was weak, which was attributed to the high stability of the Vantage frame and consequently small target displacements coupled with the sensitivity of HDMM to face mimics. This work demonstrated that the Vantage frame possess the same degree of submillimeter stability as the well-established Leksell Coordinate Frame G (G-frame). Displacements between CT and CBCT1 were 3 times higher than between CBCT1 and CBCT2. A suggested HDMM threshold of 1.2 mm ensures a target accuracy within 0.2 mm in Vantage frame treatments.