J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

Radiosurgery is a non-invasive treatment modality using focused radiation to target brain tumors, AVMs, and functional targets with sub-millimetric precision.

Below is a classification of the main systems used globally in neurosurgery:

• Modality: Cobalt-60 based photon beams
• Indications: Intracranial only
• Notable models: Perfexion®, Icon™
• Strengths:
  • High precision (sub-mm)
  • Proven track record (>1 million patients treated)
  • Widely used for AVMs, vestibular schwannomas, trigeminal neuralgia
• Limitations:
  • Requires rigid head frame (except Icon with mask-based option)
  • Cranial-only use

• Modality: Linear accelerator with robotic arm
• Indications: Cranial + body
• Strengths:
  • Frameless, non-isocentric delivery
  • Real-time motion tracking (Synchrony®)
  • Useful for irregular and multiple brain metastases
• Limitations:
  • Longer treatment times
  • Lower cranial-specific adoption

• Modality: Self-shielded gyroscopic LINAC
• Indications: Intracranial and head & neck
• Strengths:
  • No need for vault/shielded room
  • Designed specifically for neurosurgeons/radiosurgeons
  • Modern targeting and imaging suite
• Limitations:
  • New market entrant (adoption limited)
  • Few long-term clinical outcome studies

• Modality: LINAC with advanced positioning
• Use: Platform for multiple linear accelerators (e.g. TrueBeam, Versa HD)
• Strengths:
  • Sub-mm accuracy via ExacTrac
  • Versatile (integrates with multiple LINACs)
• Limitations:
  • Not a standalone radiosurgery device—relies on partner hardware

• Modality: LINAC with image-guidance
• Indications: Body + brain
• Strengths:
  • Widely used in radiation oncology
  • RapidArc, HyperArc for intracranial radiosurgery
• Limitations:
  • General-purpose; cranial radiosurgery is not primary focus

• Modality: LINAC-based SRS system
• Indications: Intracranial and extracranial
• Strengths:
  • Combines precise beam shaping with IGRT
  • Often paired with couch and respiratory motion management
• Limitations:
  • Still shares base platform with standard radiotherapy LINACs

• Modality: Helical IMRT
• Use: Spine and craniospinal cases; rarely primary choice for brain SRS
• Strengths:
  • Excellent for extended fields (e.g. craniospinal irradiation)
• Limitations:
  • Not optimized for single-lesion radiosurgery

Neurosurgical radiosurgery is evolving rapidly. Among current technologies, only a few show clear potential for long-term leadership in precision, cost-efficiency, and adaptability.

• 🥇 Zap-X: Compact, frameless, self-shielded, and neurosurgery-specific. Poised to disrupt.
• 🥈 Gamma Knife Icon: Proven gold standard, now frameless. Stable, conservative.
• ⚠️ CyberKnife: Flexible but unfocused. Needs reinvention to avoid obsolescence.

The future belongs to dedicated, AI-ready systems with low setup cost, no vault, and optimized cranial workflows.

• Cost per Treatment: Average operational + amortized capital cost per session.
• Treatment Time: Time per radiosurgical session for a single cranial lesion.
• Setup Cost: Estimated infrastructure and hardware investment.
• Brain-Specific: Designed specifically for cranial neurosurgical use.
• Vault Requirement: Needs radiation-shielded vault (adds to infrastructure cost).
• AI/Automation Ready: Includes or supports motion tracking, adaptive therapy, AI planning.

Zap-X is the only system designed exclusively for cranial radiosurgery, offering a future-ready, cost-efficient, and patient-friendly platform. It combines clinical focus with infrastructure flexibility, making it ideal for both private and public neurosurgical centers.

Zap-X enables:

• Cost-efficient radiosurgery in non-hospital settings
• Rapid ROI for private clinics and university spin-offs
• Expansion into underserved regions where vault construction is not feasible
• True ownership and control by neurosurgeons

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