• Daniel M. Trifiletti
  • Eric J. Lehrer
  • Jason P. SheehanEmail author


Radiosurgery is a blending of radiosurgery and radiation techniques that was pioneered by Dr. Lars Leksell at the Karolinska Institute in Stockholm, Sweden. This technique involves the ablation of intracranial targets and induction of desired biological effects in target tissues through the use of a high dose of highly conformal ionizing beams through the body. This technique has evolved over time to include the delivery of anywhere between one and five treatments or fractions. Since radiosurgery often involves targeting small radiographically deep lesions within the brain and spine, precision is absolutely essential and is readily obtained by immobilization. The vast majority of clinical experience with radiosurgery has been using photon-based sources, such as the Gamma Knife®, Cyberknife®, or other linear accelerator (LINAC)-based platforms. There are also facilities delivering radiosurgery with charged particles (e.g., protons). There are many similarities in both the delivery and physical principles between conventionally fractionated radiation therapy and radiosurgery. However, there are distinct differences between these two modalities which are employed by clinicians to maximize benefits to patients. This chapter will focus on the unique nature of radiosurgery with regard to medical physics and radiation biology.


Radiosurgery Radiation Stereotactic Oncology Cancer Radiobiology Medical physics 





Arteriovenous malformation




Computerized tomography


Clinical target volume


Deoxyribonucleic acid


Dynamically penalized maximum likelihood


Fast spin echo


Gross target volume




Intensity-modulated radiosurgery


Linear accelerator


Multileaf collimators


Magnetic resonance


Magnetic resonance imaging


Planned target volume


Stereotactic radiosurgery


United States




  1. 1.
    Leksell L. The stereotaxic method and radiosurgery of the brain. Acta Chir Scand. 1951;102(4):316–9.Google Scholar
  2. 2.
    Elekta surpasses one million patients treated with Leksell Gamma Knife [press release]. Stockholm, SE2016.Google Scholar
  3. 3.
    Park HS, Wang EH, Rutter CE, Corso CD, Chiang VL, Yu JB. Changing practice patterns of Gamma Knife versus linear accelerator-based stereotactic radiosurgery for brain metastases in the US. J Neurosurg. 2016;124(4):1018–24.CrossRefGoogle Scholar
  4. 4.
    Dale RG. The application of the linear-quadratic dose-effect equation to fractionated and protracted radiotherapy. Br J Radiol. 1985;58(690):515–28.CrossRefGoogle Scholar
  5. 5.
    Fowler JF. The linear-quadratic formula and progress in fractionated radiotherapy. Br J Radiol. 1989;62(740):679–94.CrossRefGoogle Scholar
  6. 6.
    Hall EJ, Giaccia A. Radiobiology for the radiologist. 6th ed. Philadelphia: Lipincott Williams & Wilkins; 2006.Google Scholar
  7. 7.
    Hall EJ, Brenner DJ. The radiobiology of radiosurgery: rationale for different treatment regimes for AVMs and malignancies. Int J Radiat Oncol Biol Phys. 1993;25(2):381–5.CrossRefGoogle Scholar
  8. 8.
    Flickinger JC, Kalend A. Use of normalized total dose to represent the biological effect of fractionated radiotherapy. Radiother Oncol. 1990;17(4):339–47.CrossRefGoogle Scholar
  9. 9.
    Wu A. Physics and dosimetry of the gamma knife. Neurosurg Clin N Am. 1992;3(1):35–50.CrossRefGoogle Scholar
  10. 10.
    Kerkmeijer LG, Fuller CD, Verkooijen HM, Verheij M, Choudhury A, Harrington KJ, et al. The MRI-linear accelerator consortium: evidence-based clinical introduction of an innovation in radiation oncology connecting researchers, methodology, data collection, quality assurance, and technical development. Front Oncol. 2016;6:215.CrossRefGoogle Scholar
  11. 11.
    Sheehan JP, Starke RM, Mathieu D, Young B, Sneed PK, Chiang VL, et al. Gamma Knife radiosurgery for the management of nonfunctioning pituitary adenomas: a multicenter study. J Neurosurg. 2013;119(2):446–56.CrossRefGoogle Scholar
  12. 12.
    Leber KA, Bergloff J, Pendl G. Dose-response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery. J Neurosurg. 1998;88(1):43–50.CrossRefGoogle Scholar
  13. 13.
    Kuo JS, Chen JC, Yu C, Zelman V, Giannotta SL, Petrovich Z, et al. Gamma knife radiosurgery for benign cavernous sinus tumors: quantitative analysis of treatment outcomes. Neurosurgery. 2004;54(6):1385–93; discussion 93–4.CrossRefGoogle Scholar
  14. 14.
    Liu AL, Wang C, Sun S, Wang M, Liu P. Gamma knife radiosurgery for tumors involving the cavernous sinus. Stereotact Funct Neurosurg. 2005;83(1):45–51.CrossRefGoogle Scholar
  15. 15.
    Sheehan JP, Pouratian N, Steiner L, Laws ER, Vance ML. Gamma Knife surgery for pituitary adenomas: factors related to radiological and endocrine outcomes. J Neurosurg. 2011;114(2):303–9.CrossRefGoogle Scholar
  16. 16.
    Minniti G, Scaringi C, Clarke E, Valeriani M, Osti M, Enrici RM. Frameless linac-based stereotactic radiosurgery (SRS) for brain metastases: analysis of patient repositioning using a mask fixation system and clinical outcomes. Radiat Oncol. 2011;6:158.CrossRefGoogle Scholar
  17. 17.
    Khoshbin Khoshnazar A, Bahreyni Toossi MT, Hashemian A, Salek R. Development of head docking device for linac-based radiosurgery with a Neptun 10 PC linac. Physica medica: PM: an international journal devoted to the applications of physics to medicine and biology: official journal of the Italian Association of Biomedical. Physics. 2006;22(1):25–8.Google Scholar
  18. 18.
    Yin FF, Ryu S, Ajlouni M, Yan H, Jin JY, Lee SW, et al. Image-guided procedures for intensity-modulated spinal radiosurgery. Technical note. J Neurosurg. 2004;101(Suppl 3):419–24.CrossRefGoogle Scholar
  19. 19.
    Murphy MJ, Chang SD, Gibbs IC, Le QT, Hai J, Kim D, et al. Patterns of patient movement during frameless image-guided radiosurgery. Int J Radiat Oncol Biol Phys. 2003;55(5):1400–8.CrossRefGoogle Scholar
  20. 20.
    Agazaryan N, Tenn SE, Desalles AA, Selch MT. Image-guided radiosurgery for spinal tumors: methods, accuracy and patient intrafraction motion. Phys Med Biol. 2008;53(6):1715–27.CrossRefGoogle Scholar
  21. 21.
    Lawrence JH, Tobias CA, Born JL, Mc CR, Roberts JE, Anger HO, et al. Pituitary irradiation with high-energy proton beams: a preliminary report. Cancer Res. 1958;18(2):121–34.PubMedGoogle Scholar
  22. 22.
    Larsson B, Leksell L, Rexed B, Sourander P, Mair W, Andersson B. The high-energy proton beam as a neurosurgical tool. Nature. 1958;182(4644):1222–3.CrossRefGoogle Scholar
  23. 23.
    Boone ML, Lawrence JH, Connor WG, Morgado R, Hicks JA, Brown RC. Introduction to the use of protons and heavy ions in radiation therapy: historical perspective. Int J Radiat Oncol Biol Phys. 1977;3:65–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Daniel M. Trifiletti
    • 1
  • Eric J. Lehrer
    • 2
  • Jason P. Sheehan
    • 3
    Email author
  1. 1.Department of Radiation OncologyMayo ClinicJacksonvilleUSA
  2. 2.Department of Radiation OncologyIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.Department of Neurological SurgeryUniversity of VirginiaCharlottesvilleUSA

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