Exactrac Dynamic Surface CUG & Dynamic STUG Combined

EXACTRAC 

DYNAMIC 

EXACTRAC DYNAMIC SURFACE 

Version 2.0 

Clinical User Guide 

Revision 1.0 

Date of issue: 2023-11-15 (ISO 8601) 

Copyright 2023, Brainlab AG Germany. All rights reserved.

TABLE OF CONTENTS 


1 GENERAL INFORMATION.............................................................................................5 

1.1 Contact Data ........................................................................................................................................5 

1.2 Legal Information ...............................................................................................................................6 

1.3 Symbols................................................................................................................................................9 

1.4 Using the System .............................................................................................................................11 

1.5 Compatibility with Medical Devices .............................................................................................15 

1.6 Cybersecurity and Software Environment..................................................................................17 

1.7 ExacTrac Dynamic Network Integration (IEC 80001) ................................................................23 

1.8 User Management.............................................................................................................................27 

1.9 Technical Requirements For ExacTrac Dynamic Preparation Application..........................29 

1.10 Training and Documentation .......................................................................................................31 

2 CLINICAL OVERVIEW .....................................................................................................33 

2.1 Using ExacTrac Dynamic in a Clinical Setting...........................................................................33 

2.2 ExacTrac Dynamic Integration with Specific Linacs ................................................................38 

2.3 Positioning with Varian or Elekta..................................................................................................41 

3 GETTING STARTED ..........................................................................................................42 

3.1 Preparing for Treatment ..................................................................................................................42 

3.2 Prepositioning Contour...................................................................................................................43 

3.3 About Patient Positioning...............................................................................................................44 

3.4 Room Lighting Conditions .............................................................................................................45 

3.5 Avoiding Collisions..........................................................................................................................46 

3.6 Technical Considerations ...............................................................................................................47 

3.7 Patient Data Prerequisites..............................................................................................................49 

4 SYSTEM STARTUP AND SHUTDOWN............................................................50 

4.1 About System Startup and Shutdown .........................................................................................50 

2 Clinical User Guide Rev. 1.0 ExacTrac Dynamic Ver. 2.0


4.2 Starting the ExacTrac Dynamic Software....................................................................................53 

4.3 Background Services ......................................................................................................................54 

4.4 Restarting the System .....................................................................................................................56 

4.5 Shutting Down the Software ..........................................................................................................57 

4.6 Shutting Down the System.............................................................................................................58 

4.7 Overview of Available Applications..............................................................................................60 

5 PREPARATION .......................................................................................................................61 

5.1 Using the Preparation Application ...............................................................................................61 

5.2 Plan Selection ...................................................................................................................................63 

5.3 Template Selection...........................................................................................................................66 

5.4 Template Editor.................................................................................................................................67 

5.5 Treatment Plan Settings..................................................................................................................70 

5.6 Preparation Workflows....................................................................................................................76 

5.7 Isocenters Overview ........................................................................................................................77 

5.8 Finish Patient Preparation..............................................................................................................80 

6 TREATMENT.............................................................................................................................81 

6.1 Overview of Available Workflows .................................................................................................81 

6.1.1 External Positioning Workflow ..........................................................................................................82 

6.1.2 Breath-hold Workflow .......................................................................................................................83 

6.2 Loading and Confirming Plans .....................................................................................................86 

6.3 Patient Feedback System ...............................................................................................................89 

6.4 Patient Prepositioning.....................................................................................................................92 

6.4.2 Prepositioning .................................................................................................................................93 

6.4.3 External Positioning with Surface Monitoring Workflows ..................................................................96 

6.4.4 Prepositioning in Breath-hold Workflows ..........................................................................................98 

6.5 Surface Tracking Area ..................................................................................................................100 

6.6 Breath-hold Respiratory Point ....................................................................................................104 

6.7 Breath-hold Navigation .................................................................................................................106 

6.7.1 Breath-hold External Positioning with Surface Monitoring ..............................................................106 

6.8 External Imaging.............................................................................................................................123 

6.9 Patient Monitoring..........................................................................................................................125 

7 BEAM MAPPING.................................................................................................................132 

Clinical User Guide Rev. 1.0 ExacTrac Dynamic Ver. 2.0 3


7.1 About Beam Mapping ....................................................................................................................132 

8 SYSTEM CALIBRATION AND DAILY CHECK SURFACE ............136 

8.1 About Performing Calibrations ...................................................................................................136 

8.2 About 3D Camera Warm-Up .........................................................................................................138 

8.3 Calibration Workflows ...................................................................................................................140 

8.3.1 Performing Thermal to 3D Camera Calibration...............................................................................141 

8.3.2 Performing Isocenter Calibration Surface .......................................................................................144 

8.4 Daily Check Surface.......................................................................................................................147 

8.5 Surface Tracking QA......................................................................................................................150 

9 REVIEWING PATIENT DATA....................................................................................153 

9.1 Reviewing Patient Data .................................................................................................................153 

9.2 Repeat Export..................................................................................................................................154 

9.3 Archive/Delete Patients.................................................................................................................156 

9.4 Generating Treatment Reports ....................................................................................................158 

10 ALGORITHMS ....................................................................................................................159 

10.1 Calibration......................................................................................................................................159 

10.2 Surface Tracking...........................................................................................................................160 

11 APPENDIX..............................................................................................................................162 

11.1 Preparation Software Revalidation Workflow ........................................................................162 

11.2 Status Information........................................................................................................................163 

11.3 System Messages.........................................................................................................................167 

11.4 Abbreviations ...............................................................................................................................183 

INDEX ..................................................................................................................................................184 


GENERAL INFORMATION 

1 GENERAL INFORMATION 

1.1 Contact Data 

Support 

If you cannot find information you need in this guide, or if you have questions or problems, contact 

Brainlab support: 

Region Telephone and Fax Email 

United States, Canada, Central 

and South America 

Tel: +1 800 597 5911 

Fax: +1 708 409 1619 

us.support@brainlab.com 

Brazil Tel: 0800 892 1217 brazil.support@brainlab.com 

UK Tel: +44 1223 755 333 

Spain Tel: +34 900 649 115 

France and French-speaking 

regions 

Africa, Asia, Australia, Europe 

Japan 

Tel: +33 800 676 030 

Tel: +49 89 991568 1044 

Fax: +49 89 991568 5811 

Tel: +81 3 3769 6900 

Fax: +81 3 3769 6901 

support@brainlab.com 

Expected Service Life 

Brainlab provides ten years of service for system components. During this period of time, spare 

parts as well as field support are offered. If the software remains in service after the end of 

support, the cybersecurity risks may increase over time. 

Feedback 

Despite careful review, this user guide may contain errors. Please contact us at 

user.guides@brainlab.com if you have improvement suggestions. 

Manufacturer 

Brainlab AG 

Olof-Palme-Str. 9 

81829 Munich 

Germany 


Legal Information 

1.2 Legal Information 

Copyright 

This guide contains proprietary information protected by copyright. No part of this guide may be 

reproduced or translated without express written permission of Brainlab. 

Brainlab Trademarks 

Brainlab ® , Brainlab Connected Care ® , Brainlab Elements ® , ExacTrac Dynamic and ExacTrac 

Dynamic Surface ® are registered trademarks of Brainlab AG or an affiliated company. 

NOTE: See brainlab.com/trademarks for details. 

Non-Brainlab Trademarks 

To the knowledge of Brainlab AG, the following trademark information applies: 

• ARIA OIS, Edge, TrueBeam, VitalBeam and PerfectPitch are registered trademarks of Varian 

Medical Systems, Inc. 

• eBUS is a registered trademark of Pleora Technologies Inc. 

• Elekta, iGUIDE, HexaPOD, MOSAIQ and Response are registered trademarks of Elekta AB. 

• Laird is a registered trademark of Laird Thermal Systems GmbH. 

• Bitlocker, Microsoft and Windows are registered trademarks of Microsoft Corporation. 

• NVIDIA is a trademark and/or registered trademark of NVIDIA Corporation in the US and/or 

other countries. 

• Varex and Varex Imaging are registered trademarks of Varex Imaging Corporation in the US 

and/or other countries. 

Patent Information 

This product may be covered by one or more patents or pending patent applications. For details, 

see: www.brainlab.com/patent. 

Integrated Third-Party Software 

This software is based in part on the following work. Full license and copyright notices can be 

found here: https://blguides.com/third-party-software-licenses 

Software Version Software Version 

ACE 6.5.8 LightBurst 1.6.0 

Chromium Embedded 

Framework (CEF) 

79.1.38+gecefb59 

+chromium-79.0.3945.13 

0 

Merge DICOM Toolkit 5.12.0 

C++ REST SDK 2.10.14 meta 0.1.0 

cryptopp 8.1.0 Modernizr 2.8.3 

d3js 3.5.17 nicescroll 3.6.0 

durandal 2.1.0 node.js 12.13.1 

eigen 3.4.0 Nvidia NVAPI release 367 

Filament 1.4.0 OpenCV 4.7.0 

FTD2XX 2.12.36 openjpeg 2.4.0 




FX11 4.2.0 pdf.js 1.4.20 

ICU 1.8.1 range-v3 0.5.0 

jquery 2.1.4 react.js 16.8.6 

jqueryui 1.11.1 RenderDocAPI 1.4.0 

knockout 3.5.1 requirejs 2.3.5 

LAPACK 3.2.1 SolvOpt 1.2 

libjpeg 2.1.2, 6b UltraVNC 1.3.8.1 

libjpeg-turbo 2.1.2 Xerces-C++ 3.2.3 

LibJpeg16, LibJpeg8 3.6.0, 6b yajl 2.1.0 

LibJpeg2k 2.4.0 zlib 1.2.12 

libpng 1.6.37 Xerces-C++ 3.2.3 

libtiff 3.6.0 

CE Label 

The CE label indicates that the Brainlab product complies with the General Safety 

and Performance Requirements of European Regulation 2017/745, the Medical 

Device Regulation ("MDR"). 

ExacTrac Dynamic is a Class IIb product according to the rules established by 

the MDR. 

Report Incidents Related to This Product 

You are required to report any serious incident that may have occurred related to this product to 

Brainlab, and if within Europe, to your corresponding national competent authority for medical 

devices. 

Registration, Evaluation and Authorization of Chemicals (REACH) 

REACH is the European chemicals law that came into force to improve the protection of human 

health and the environment from risks that can be posed by chemicals. The identification of a 

substance as a substance of very high concern and its inclusion in the candidate list for REACH 

creates certain legal obligations for the importers, producers and suppliers of an article that 

contains such a substance. Brainlab requests suppliers to inform whether and to what extent 

substances from the list are used in their products. For further information regarding REACH 

processes at Brainlab, contact us here: 

www.brainlab.com/reach/ 

Electronic Product Radiation Control (EPRC) Program (US Only) 

According to the EPRC program of the FDA, ExacTrac Dynamic is classified as a medical 

charged-particle radiation therapy system (Accelerator, Linear, Medical), radiation-emitting product 

code IYE. 

Based on 21 CFR (Code of Federal Regulations Title 21) of the CDRH, no performance standard 

is applicable and General Radiological Health requirements apply (21 CFR 1000-1005). 

Packaging and Packaging Disposal 

No special disposal of the packaging material is required. 



Disposal Instructions 

When a medical device reaches the end of its functional life, clean the device of all biomaterial/ 

biohazards and safely dispose of the device in accordance with applicable laws and regulations. 

Only dispose of electrical and electronic equipment in accordance with statutory regulations. 

For information regarding the WEEE (Waste Electrical and Electronic Equipment) 

directive or relevant substances that could be present in the medical equipment, 

visit: 

https://www.brainlab.com/sustainability/ 

https://www.brainlab.com/about-brainlab/technology/weee/ 

Warranty 

Warranties do not apply to products that have been damaged due to accidents, misuse, 

improper reinstallation, or inadequate packaging in the case of return shipments. 

Warranties do not apply to product components that have been modified or replaced 

without the written authorization of Brainlab. 

IEC Compliance 

In accordance with radiation protection, ExacTrac Dynamic is compliant to IEC 60601-2-68:2014. 



1.3 Symbols 

Warnings 

Warning 

Warnings are indicated by triangular warning symbols. They contain safety-critical 

information regarding possible injury, death or other serious consequences associated 

with device use or misuse. 

Cautions 

Cautions are indicated by circular caution symbols. They contain important information 

regarding potential device malfunctions, device failure, damage to device or damage to 

property. 

Notes 

NOTE: Notes are formatted in italic type and indicate additional useful hints. 

Product Symbols 

The below symbols may be found on the system. 

Symbol 

Explanation 

Unique device identifier 

Medical device 

Manufacturer's serial number 

Manufacturer's batch code 

Article number 

Swiss authorized representative 

Manufacturer 

Date of manufacture 

NOTE: The date is expressed as in ISO 8961 as YYYY-MM-DD. 

Consult instructions for use 

U.S. federal law restricts this device to sale by or on order of a physician 


Symbols 

Symbol 

Explanation 

Temperature limit 

NOTE: Indicates the temperature limits to which the medical device can be safely 

exposed. 

Humidity limitation 

NOTE: Indicates the range of humidity to which the medical device can be safely exposed. 

Atmospheric pressure limitation 

NOTE: Indicates the range of atmospheric pressure to which the medical device can 

be safely exposed. 

Follow the instructions for use 

Waste Electrical and Electronic Equipment 

Warning; radioactive material or ionizing radiation 

Warning; electricity 

Hot surface 



1.4 Using the System 

Abbreviated Device Description 

ExacTrac Dynamic (ETD) is a patient positioning and monitoring device used in a radiotherapy 

environment as an add-on system to standard linear accelerators (linacs). It uses radiotherapy 

treatment plans and the associated computed tomography (CT) data to determine the patient's 

planned position and compares it via oblique X-ray images to the actual patient position. The 

calculated correction shift will then be transferred to the treatment machine to align the patient 

correctly at the machine's treatment position. During treatment, the patient is monitored with a 

thermal-surface camera and X-ray imaging to ensure that there is no misalignment due to patient 

movement. Positioning and monitoring are also possible in combination with implanted markers. 

By defining the marker positions, ExacTrac Dynamic can position the patient by using X-rays and 

thereafter monitor the position during treatment. 

Additionally, ExacTrac Dynamic features a breath-hold (BH) functionality to serve as a tool to 

assist respiratory motion management. This functionality includes special features and workflows 

to correctly position the patient at a BH level and thereafter monitor this position using surface 

tracking. Regardless of the treatment indication, a correlation between the patient’s surface and 

internal anatomy must be evaluated with Image-Guided Radiation Therapy. The manually 

acquired X-ray images support a visual inspection of organs at risk (OARs). The aim of this 

technique is to treat the patient only during breath hold phases where the treatment target is at a 

certain position to reduce respiratory-induced tumor motion and to ensure a certain planned 

distance to OARs such as the heart. In addition to the X-ray based positioning technique, the 

system can also monitor the patient after external devices such as Cone-Beam CT (CBCT has 

been used to position the patient). 

The ExacTrac Dynamic Surface (ETDS) is a camera-only platform without the X-ray system and 

is available as a configuration which enables surface-based patient monitoring. This system 

includes an identical thermal-surface camera, workstation, and interconnection hardware to the 

linac as the ETD system. The workflows supported by ETDS are surface based only and must be 

combined with an external IGRT device (e.g., CBCT). 

Intended Purpose 

The device supports radiotherapy and radiosurgery. 

Intended Use and Indications for Use 

ExacTrac Dynamic is intended to position patients at an accurately defined point within the 

treatment beam of a medical accelerator for stereotactic radiosurgery or radiotherapy procedures, 

to monitor the patient position and to provide a beam hold signal in case of a deviation in order to 

treat lesions, tumors and conditions anywhere in the body when radiation treatment is indicated. 

Intended Patient Population 

ExacTrac Dynamic is intended for all patients undergoing Radiotherapy or Radiosurgery 

treatments. There are no physiological limitations or restrictions regarding age, weight, gender, 

etc. 

Intended Part of the Body or Type of Tissue Applied to or Interacted With 

The system consists of many components with different functions and locations. Body contact 

does not affect all components in the same way. 

Most components of the system, like X-ray generators, are out of reach for the user and patient. 

Other components, like covers and units mounted on the ceiling, are not reachable or not meant 

to be touched by users or patients during intended use. 

Body contact is instead expected for the following categories of components: 

• Phantoms, required to calibrate the system, have only user contact. They are handled by the 

user and no patient contact is expected nor foresee. The user picks them up from the storage 


Using the System 

location and positions them where appropriate according to the selected calibration procedure 

and proceed with the calibration or daily check. Optional tools (e.g., X-ray QA support device) 

needed to carry out specific tests can also be included in this category. 

• Electronic interfaces required for the user to interact with the system. No patient contact is 

expected for these components. 

• ExacTrac Dynamic Patient Feedback System is a component of the system that is meant to 

help the patient follow the breathing instructions when using breath-hold functionality. The 

device is firstly clamped to the couch-top by the user and it requires afterwards a fine 

adjustment to reach the desired position. This adjustment can be performed by the user or 

directly by the patient. The adjustment is done by means of handles located at both sides of the 

mirror. As an alternative to this device, the customer is provided also with the article ExacTrac 

Dynamic Patient Feedback Glasses. The article is worn directly by the patient during a BH 

treatment similarly to standard optical glasses. 

Intended User Profile 

The intended users of ExacTrac Dynamic are medical professionals, who are qualified according 

to country and hospital specific regulations to provide (apply) radiation therapy treatments (e.g., 

Radiation Therapist, Radiation Oncologist/Physician, Medical Physicist/Physicist, Dosimetrists). 

ExacTrac Dynamic-specific roles: 

• Radiation Technologist, Technician, Radiographer (MTR) 

- Schedule, prepare patient for patient positioning 

- Patient positioning 

- Patient's motion monitoring during treatment 

- QA task, if they have extended education 

• Medical Physicist (MP): 




- System calibration 

• Radiation Oncologist (RO): 

- Supervise patient's motion monitoring during treatment 

• Patients 

- Adjust and use mirror and user interface for breathing feedback 

Intended Use Environment 

For both ExacTrac Dynamic and ExacTrac Dynamic Surface shall be installed in a treatment 

room within a hospital radiation therapy department. 

ExacTrac Dynamic and ExacTrac Dynamic Surface have a surface-tracking-camera system 

installed in the treatment room. 

For ExacTrac Dynamic two flat panels are mounted to the ceiling and two X-ray tubes are 

embedded in the floor or placed on top of the floor (on-floor installations). 

For both versions the main device used to control ExacTrac Dynamic or ExacTrac Dynamic 

Surface is a console that is located outside of the treatment room. Keyboard and monitor are also 

provided. A touchscreen is mounted inside the treatment room. 

A stable electrical and IT environment (min 1000 Base-T, Latency > 100 ms) is prerequisite for the 

use of ExacTrac Dynamic. 

Environmental conditions are as follows: 

Operating Conditions 

Storage Conditions 

Humidity range 30% to 70% 15% to 75%, non-condensing 

Ambient temperature 16 °C to 35 °C -10 °C to 50 °C 

Atmospheric pressure 800 hPa to 1013 hPa 700 hPa to 1013 hPa 



Performance Characteristics 

ExacTrac Dynamic shall provide a translation accuracy better than 1.0 mm and a rotational 

accuracy better than 1.0° for a rigid body. 

The surface deviation shall be better than 1.5 mm and 1° for rigid body. For the breath-hold the 

accuracy shall be better than 2 mm. 

Essential Performance Characteristics 

A 

B1 

B2 

C 

D 

E 

If a surface based deviation between reference and detected patient position is indicated 

and if an allowed tolerance for these values is defined, this deviation is calculated and 

shown with an accuracy of 1.5 mm and 1° for a rigid body. 

If an X-ray and anatomy based deviation between planned and detected patient position 

is indicated, this deviation is calculated and shown with an accuracy of 1 mm and 1° for a 

rigid body. 

If an X-ray and implanted marker based deviation between planned and detected patient 

position is indicated, this deviation is calculated and shown with an accuracy of 1 mm and 

1° for a rigid body. 

Providing shift values to a third-party patient support system as confirmed by the user. 

Providing a "beam hold" signal at the ExacTrac Dynamic hardware output to the thirdparty 

linac within 1s after a deviation between planned and actual patient position exceeding 

tolerance limits was detected. 

Indicating a deviation between actual and planned patient position during breath-hold 

based on surface tracking with an accuracy of 2 mm. 

Contraindications 

ExacTrac Dynamic X-ray imaging radiation, and the therapeutic treatment radiation, can 

potentially have detrimental interaction with active implantable medical devices such as 

pacemakers and active medical devices worn on the body. To prevent injury to patients wearing 

pacemakers or other active implants, the implant manufacturer should be contacted regarding 

possible hazards resulting from radiation exposure. 

Side Effects and Complications 

ExacTrac Dynamic uses ionizing radiation (kV X-ray) with its generally known potential side 

effects of predominantly skin irritation. There are of course known side-effects of radiotherapy. 

However these are associated with linear accelerator treatments in general and not with the use 

of ETD for patient positioning. 

Residual Risks 

There is a danger of ionizing radiation (MV) if the treatment beam is delivered to tissue outside the 

target volume tolerances in cranial or non-cranial mode. If the user does not recognize an 

incorrect fusion due to incorrect shift values (e.g., the user is unable to distinguish between similar 

repetitive structures, such as vertebrae and ribs, in the image fusion), healthy tissue or non-target 

structures could be exposed to substantial unintended radiation. 

Clinical Benefit 

• ExacTrac Dynamic assists clinicians to accurately align the patient to the radiotherapy 

treatment device as defined in the treatment plan. 

• ExacTrac Dynamic assists clinicians to monitor the treatment position of a patient during 

treatment. 



• ExacTrac Dynamic enables clinicians to keep the IGRT imaging dose delivered to the patient 

as low as reasonably possible. 

Careful Handling of Hardware 

System components and accessory instrumentation are comprised of precise mechanical 

parts. Handle them carefully. 

Plausibility Review 

Warning 

Before patient treatment, review the plausibility of all information input to and output from 

the system. 



1.5 Compatibility with Medical Devices 

Compatible Brainlab Medical Devices 

ExacTrac Dynamic is compatible with the following Brainlab medical devices. 

Device Name Article Number UDI-DI 

Cranial 4Pi CT Overlay 43420A 04056481144241 

Cranial 4Pi Treatment Overlay 43421A 04056481144234 

Cranial 4Pi Headrest Standard 43440A 04056481144227 

Cranial 4Pi Headrest Low-Neck 43441A 04056481144210 

Cranial 4Pi Headrest Inlay Standard 2pcs 43446A 04056481144203 

Cranial 4Pi Headrest Inlay Openface 2Pcs 43447A 04056481144197 

Cranial 4Pi Headrest Inlay H&N 2Pcs 43448A 04056481144180 

Cranial 4Pi Stereotactic Mask (5 Pcs.) 43450 04056481141936 

Cranial 4Pi Basic Mask (5 Pcs.) 43451 04056481141943 

Cranial 4Pi Open Face Mask (5 Pcs.) 43452 04056481141950 

SRS 4Pi CT Table Overlay 43430 04056481141363 

Cranial 4Pi is an assembly of the following medical device/ accessory groups: 

• Cranial 4Pi Overlays 

• Cranial 4Pi Headrests 

• Cranial 4Pi Headrest Inlays 

• Cranial 4Pi Masks 

The Cranial 4Pi Overlays are medical devices used for fixation of the patient in a CT- resp. linear 

accelerator - environment. 

The Cranial 4 Pi Headrests and the Cranial 4Pi Headrest Inlays are accessories to the Cranial 4Pi 

Overlays to allow an indication specific positioning of the patient's head and neck. 

The Cranial 4Pi Masks are accessories to the Cranial 4Pi Overlays used for producing individual 

custom-made masks for patient immobilization to the Cranial 4Pi Overlay Boards. 

The Cranial 4Pi Immobilization group of devices is used for fixation and repositioning of the 

patient’s head and neck in a CT- and linear accelerator environment. The SRS 4Pi CT Table 

Overlay (43430) is a medical device used for fixation and repositioning of the patient's head and 

neck in a CT-environment. 

The mask sets Cranial 4Pi Stereotactic Mask (43450) / Cranial 4Pi Basic Mask (43451) / 

Cranial 4Pi Open Face Mask (43452) are medical devices used for producing custom-made 

masks for patient fixation to the Overlay Board in a CT- and linear accelerator environment. 

NOTE: For further details, refer to the Cranial 4Pi Hardware User Guide and Cranial 4Pi 

Immobilization Hardware User Guide. 

NOTE: ExacTrac Dynamic is not compatible with Brainlab Robotics. 

Non-Brainlab Medical Devices 

ExacTrac Dynamic is compatible with the following non-Brainlab medical devices only. Do not 

use with any other devices. 

It is a prerequisite that the linac is calibrated correctly. 

For further questions about compatibility, contact Brainlab support. 


Compatibility with Medical Devices 

Device Description Interface Manufacturer 

Data and signal lines: 

TrueBeam Radiotherapy 

System 

Linear Accelerator 

TrueBeam Auxiliary 

Device Interface (ADI 

3.0) 

TrueBeam External 

gating interface (EXGI 

2.0) 

Varian Medical Systems, 

Inc. 

3100 Hansen Way 

Palo Alto, CA 94304 

ARIA oncology information 

system 

Record & Verify (R&V) 

System 

LAN connection, DI- 

COM 


Elekta Linear Accelerator 

MOSAIQ, Patient Positioning 

Systems Interface 

(PPS WebIF) 


Record & Verify System 

Elekta iGUIDE GMI 

Elekta Response gating 

interface 

Elekta iCOM Vx 


COM 

Elekta Limited Cornerstone 

London Road Crawley 

West Sussex RH10 

9BL 

United Kingdom 

NOTE: Brainlab recommends contacting Brainlab support if any linac software or hardware needs 

to be changed or updated. 

Warning 

Brainlab recommends contacting Brainlab support if settings on the linac need to be 

changed after installation. 

Non-Brainlab Devices 

Warning 

Using medical device combinations that have not been authorized by Brainlab may 

adversely affect safety and/or effectiveness of the devices and endanger the safety of the 

patient, user and/or environment. 

DICOM Conformance 

DICOM conformance statements can be found on the Brainlab website at: www.brainlab.com/ 

dicom. 

DICOM Functionality and Interoperability 

DICOM, by itself, does not guarantee interoperability. However, the conformance statement 

facilitates a first-level validation for interoperability between different applications supporting the 

same DICOM functionality. The conformance statement should be read and understood in 

conjunction with the DICOM standard. 

NOTE: ExacTrac Dynamic requires a DICOM RT data set to perform as intended. 



1.6 Cybersecurity and Software Environment 

Bill of Materials of Integrated Third-Party Software 


ACE 6.5.8 Merge DICOM Toolkit 5.12.0 

AltSoft XML2PDF Formatting 

Engine 

2.1.2.230 meta 0.1.0 

Brainlab Connected Care 1.2.2.4 Modernizr 2.8.3 

Chelsio viewwire 6.16.1.0 nicescroll 3.6.0 



79.1.38+gecefb59 

+chromium-79.0.3945.13 

0 

node.js 12.13.1 

cpprest 2.10.14 Notepad++ 8.5.4 

cryptopp 8.1.0 Nvidia NVAPI release 367 

d3js 3.5.17 Nvidia Quadro Driver 535.98 

durandal 2.1.0 OpenCV 4.7.0 

eBusSDK 3.1.0 openjpeg 1.4.0 

FX11 4.2.0 pdf.js 1.4.20 

eigen 3.4.0 range-v3 0.5.0 

Elekta Gmp 2.1.0 react.js 16.8.6 

Elekta iCOM, iCOMx86 5.14 renderdocapi 1.4.0 

Elekta MSQ 2.0.0 requirejs 2.3.5 

Elekta Responsex86 1.0.13 SolvOpt 1.2 

Filament 1.4.1 SpinnakerSDK 2.7.0.128 

Finder Toolbox NFC 3.6.1 SQLite 3.26.0 

FTD2XX 2.12.36 Thingworx 8.5.18 

ICU 1.8.1 UltraVNC 1.3.8.1 

Intel wired driver 27.7 Varex Viva64 Virtual CP L08 2.2 

jquery 2.1.4 

jqueryui 1.11.1 

kineticjs 5.1.0 

knockout 3.5.1 

LAPACK 3.2.1 

libjpeg 

2.1.2, 6b 

libjpeg-turbo 2.1.2 

LibJpeg16, LibJpeg8 3.6.0, 6b Windows 10 

Varex Virtual CP Software 

Interface 

Visual C++ redistributable 

x86 2008 


x86 2010 


x64 2010 


x64 2012 


x64 2013 


x86 & x64 2015-2019 

L08 2.2 

9.0.30729 

10.0.30319 

10.0.40219 

11.0.61030 

12.0.21005 

14.22.27821.0 

IoT Enterprise 

version 


Cybersecurity and Software Environment 


LibJpeg2k 2.4.0 Xerces-C++ 3.2.3 

libpng 1.6.37 yajl 2.1.0 

libtiff 3.6.0 zlib 1.2.12 

LightBurst 1.6.0 

Cybersecurity Use Environment 

Cybersecurity considerations were made in accordance with the nature of the device, including 

the device type and the use environments of the system during its lifetime. 

The following common best practice security controls ("security hygiene") in the use environment 

are expected to be followed, independently of the status of the system (powered on / powered off): 

• Good physical security to prevent unauthorized physical access to the system. 

If the system is powered on, follow these additional security controls: 

• Access control measures (e.g., role based) to ensure only authenticated and authorized 

personnel are allowed access to network elements, stored information, services and 

applications. 

• Network access controls, such as segmentation, to limit medical device communication. 

• General patch management practices that ensure timely security patch updates on adjacent 

devices in the use environment. 

• Malware protection to prevent unauthorized code execution on adjacent devices in the use 

environment. 

• Ensure that prescribed maintenance is done as required, including installation of security 

patches. 

• Security awareness training of the users. 

Using the device outside of the intended operating environment may lead to cybersecurity 

incidents that may affect safety and effectiveness of the device. 

Hospital administration is responsible for limiting access to the system and the patient data to 

appropriate personnel. 

Be aware that screenshots created by the software contains patient-specific data. Saving the 

screenshot locally thereby saves patient information to the system. 

Warning 

Always follow medical network protection standards. 

Regional Legislation 

In the ExacTrac Dynamic software, patient data is identified by the patient's name and a unique 

ID. For this reason, it must be handled in accordance with the relevant confidentiality legislation 

and protected against unauthorized access. In the United States, patient data must be handled in 

accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

Data Access 

ExacTrac Dynamic receives data via DICOM Proxy from an R&V System. The externally 

accessible DICOM Proxy is located on the Patient Preparation Server. Data is stored within the 

Treatment Workstation or on the Patient Preparation Server. The two DICOM Proxys store data 

on the local file system. Access to this file system is controlled by the hospital via user access 

rights. 

For anonymization of patient data, use a certified third-party product. 

Access to Printouts 

As ExacTrac Dynamic treatment reports contain the patient name and ID, the printer must be 

located in a secure area and the printouts protected against unauthorized access. 



Data Backup 

In order to protect against patient data loss, both patient data folders need to be backed up via 

network or similar. 

Data Protection and System Disposal 

Because confidential patient data is stored on several hard drives or virtually, it is therefore 

necessary to securely erase all workstations and/or server locations where ExacTrac Dynamic or 

the Patient Preparation Server is running or physically destroy the hard drives before system 

disposal. 

Cybersecurity Vulnerability 

If you detect a cybersecurity vulnerability or weakness of the device or if a cybersecurity incident 

takes place involving the device, contact Brainlab support. Depending on the actual event, 

Brainlab support will advise which steps to take. 

Microsoft Security Updates for Windows and Driver Updates 

Brainlab allows the installation of security patches only. Do not install service packs and optional 

updates. Verify your settings to ensure updates are downloaded and installed correctly at a 

suitable time outside of clinical hours. For more information about settings and a list of Microsoft 

Security Updates blocked by Brainlab support, see the Brainlab website (brainlab.com/updates). 

Only perform Windows updates according to the Brainlab website. 

Do not update drivers on Brainlab platforms. Note that automatic driver updates are disabled. 

These shall only be performed by Brainlab support or with Brainlab approval. Neither manual 

steps nor Windows update functionality should be used to update drivers on Brainlab ExacTrac 

Dynamic Workstations. 

Updates 

Updates to the operating system or third-party software should be performed outside clinical hours 

and in a test environment to verify correct operation of the Brainlab system. Brainlab monitors the 

released Windows security updates and will know, for some updates, if problems can be 

expected. Contact Brainlab support if any problems to operating system security updates are 

encountered. 

Virus Scanning and Malware 

If the system is connected to a local area network (LAN), Brainlab recommends using malware 

protection software (e.g., virus scanner) and keeping the definition files up to date. Be aware that 

the malware protection settings can affect system performance (e.g., if each file access is 

monitored, patient data loading and saving might be slow). Therefore Brainlab recommends 

disabling real-time scans and regularly performing virus scans during non-clinical hours using an 

administrative account. 

The default Windows virus scanner, Microsoft Defender, is installed and active. 

Other anti-virus protection can be used if it does not block the communication between ExacTrac 

Dynamic and the associated hardware. The anti-virus software has to have the option to not 

interfere with the network communication between the 3D Camera, the Thermal Camera, Flat 

Panel Detectors and the treatment application (e.g., by enabling firewall exceptions). 

Requirements 

• Do not update the virus scanner software during treatment. 

• The virus scanner must not perform a hard disk drive scan during patient treatment. 



• Do not use the virus scanner in a high security mode during treatment. 

• During scans of the ExacTrac Dynamic folder (D:/Brainlab and E:/Patient), do not delete 

any files or put any files into quarantine. 

Configuration 

Brainlab recommends: 

• Configure the anti-virus software so it does not modify: 

- D:\Brainlab 

- E:\Patient 

- D:\RVExport\ 

- %userprofile%\AppData\Local\Brainlab 

• Deactivate any other anti-virus software feature such as browser/email-scanners, additional 

firewall, etc. 

Compatible Brainlab Software 

Only Brainlab software specified by Brainlab may be installed and used with the system. Contact 

Brainlab support for clarification regarding compatibility with Brainlab software. 

Non-Brainlab Software 

Only authorized Brainlab employees may install software on the Brainlab system. Do not 

install or remove any software applications. 

Information for Hospital Medical IT Network Risk Manager 

The following information is intended for the hospital Medical IT-Network Risk Manager. 

1. 

2. 

3. 

Item 

Purpose of the connection 

to the IT network 

Required IT-network characteristics 

Required IT-network configuration 

Description 

The Brainlab device can load and save patient data. 

These are transferred via DICOM Proxy from ExacTrac 

Dynamic to R&V, linac. 

The Brainlab device transfers medical imaging data and 

patient data between ExacTrac Dynamic and the Patient 

Preparation Server or between the Positioning and 

ExacTrac Dynamic applications via the local DICOM 

Proxy. 

The DICOM Proxy on the Patient Preparation Server also 

transfers medical images and data to the R&V systems 

or linac. 

The average size of a medical imaging data set transferred 

through the network is 100 - 500 MB. 

Required: 

• User management is achieved by joining the Brainlab 

device to the hospital domain and adding users to 

dedicated user groups with group management. 

• Brainlab offers remote system support which requires 

internet access. 

The Brainlab device requires firewall permissions for the 

services listed under point 4, below. 

4. 

Technical specifications of 

the network connection, including 

security specifications 

The Brainlab device includes the following network connections 

(4.1 - 4.8): 



4.1 

4.2 

4.3 

4.4 

4.5 

4.6 

Item 

Physical connection of the 

Brainlab device 

Logic connection between 

the Brainlab device and 

other Brainlab devices or 

hospital file storage 



hospital domain controller 



Brainlab support 


the Brainlab system and 

other linac (Varian) 



other linac (Elekta) 

Intended information flow 

between the Brainlab device 

and the IT network 

Description 

The system is connected to the IT-network with a 

100/1000 Base-T connection. 

• Recommended speed is 1 GBit. Minimum speed is 100 

MBit. 

• Network latency must be less than 100 ms. 

• The network must be fully switched on. 

• Protocols: CIFS 

• Ports: 445/TCP/in- and outbound 

• Protocols: Microsoft-DS, Kerberos, LDAP, DNS 

• Ports: 445/TCP/UDP/outbound, 88/TCP/UDP/ 

outbound, 389/UDP/outbound, 53/TCP/UDP/outbound 

• Protocols: Brainlab Connected Care 

• Ports: 443/TCP/outbound to: support.brainlab.com, 

gas-aus.axeda.com, ghjap1.axeda.com, ghsj1.axeda.com, 

ghsom1.axeda.com, ghuk1.axeda.com 

• Protocol: ADI (Auxiliary Device Interface) 

• Port: 56050/TCP/in- and outbound 

• Protocol: Elekta protocol 

• Port: 135, 1801, 2101 /TCP/in- and outbound 

The Brainlab device typically consists of the following information 

flow: 

5.1 User authentication 

User authentication at the Brainlab device is processed 

with the help of local user accounts or the hospital domain 

controller. 

5. 

5.2 

Loading of medical imaging 

data 

Medical imaging data is transferred via DICOM Q/R or 

pushed between the R&V. 

5.3 

Storing of modified medical 

imaging data 

Modified medical imaging data is stored on the local hard 

drive or hospital network shared drives. 

5.4 

Patient positioning and 

beam approval 

ExacTrac Dynamic and the linac system perform internal 

communication for patient positioning and beam approval. 

5.5 

Remote support through 

Brainlab 

Remote support for the Brainlab device requires a connection 

to the Brainlab support servers. 

6. 

Hazardous situation resulting 

from an IT-network failure 

A failure of the IT Network connection can cause that the 

treatment cannot be continued or must be repeated. This 

can lead to unnecessary KV Imaging of the patient. 

The following documents are available upon request: 

7. 

Technical descriptions and 

technical manuals 

• Preinstallation manual 

• FDA and CE declarations 

• DICOM conformance statements: (www.brainlab.com/ 

dicom) 

8. 

Recommended product 

configurations 

The Brainlab device will be installed and configured according 

to customer needs by the Brainlab service engineer. 

Subsequent modifications can affect the safety and 

effectiveness of the product. 

9. 

Known incompatibilities and 

restrictions 

The Brainlab device requires a network supporting IPv4. 



10. 

Item 

Product corrective actions 

and recalls 

Description 

Brainlab will inform every customer in case of identified 

anomalies. 

11. Cybersecurity notices 


cybersecurity issues and provide software updates accordingly. 

12. 

Background according to 

IEC 60601-1 3rd edition, 

chapter 14.13 (Connection 

of PEMS by NETWORK/ 

DATA COUPLING to other 

equipment) 

Connecting the Brainlab device to networks that include 

other equipment could result in previously unidentified 

risks to patients, operators or third parties. The responsible 

organization should identify, analyze, evaluate and 

control these risks. Subsequent changes to network 

could introduce new risks and require additional analysis. 

Changes to the network include: 

• Changes to the network configuration 

• Connection of additional items to the network 

• Disconnecting items from the network 

• Updating equipment connected to the network 

• Upgrade of equipment connected to the network 

Warning 

Do not use Brainlab Connected Care during linac Beam On. 



1.7 ExacTrac Dynamic Network Integration (IEC 

80001) 

Ensuring a Safe IT Network 

• Ensure a safe network connection during transferring patient data and during treatment. 

Minimum network specifications are defined by Brainlab. 

• Only install release updates from original manufacturers. 

• After the ExacTrac Dynamic and the linac installation, both systems must have dedicated, 

static IP addresses. Do not use dynamic IP addresses. 

• A stable, reliable and safe network environment and connection are required to guarantee a 

safe and effective use of the ExacTrac Dynamic system when ExacTrac Dynamic is 

connected to a network. Network problems during patient data transfer or patient treatment can 

interrupt the workflow and cause a repetition of parts of the treatment such as X-ray imaging for 

patient position. 

Standard Integration 

The following image shows a typical network setup for a standard ExacTrac Dynamic: 

1 

10 

2 

3 

11 

4 

5 

6 

7 

8 

9 

Figure 1 


ExacTrac Dynamic Network Integration (IEC 80001) 

No. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

Description 

Hospital Network 

Varian/ADI 

Treatment Workstation 

DICOM Data 

Patient Preparation Server (mandatory for multiple systems, optional for single system 

sites) 

Hospital R&V 

Internet 

Remote Access 

Brainlab Connected Care Support 

Linac Network 

Linac 

NOTE: The system for the ExacTrac Dynamic Patient Preparation Server should be provided by 

the customer (Server or Virtual Machine) or purchased from Brainlab (Server). 

Elekta Integration 

The following image shows a typical network setup for ExacTrac Dynamic with an Elekta 

integration: 



10 

3 

11 

2 

1 

4 

5 

6 

7 

8 

9 

Figure 2 

No. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

Description 


Elekta Firewall 


DICOM Data 


sites) 

Hospital R&V 

Internet 

Remote Access 


Elekta Network 

Linac 





About Data Transferred to and From ExacTrac Dynamic 

DICOM Proxy pushes incoming data (e.g., RT images) to ExacTrac Dynamic. ExacTrac 

Dynamic asks DICOM Proxy to send on outgoing data (e.g., to ARIA). ExacTrac Dynamic does 

not have physical limits for sending and receiving data except those set by DICOM Proxy and the 

hardware itself. 

DICOM Proxy on the Patient Preparation Server exchanges data with DICOM Proxy on the 

Treatment Workstation (e.g., RT images) from where ExacTrac Dynamic received its data. 

A backup of the system must be performed periodically. 

ExacTrac Dynamic can handle the following data types: DICOM and PDF (e.g., for treatment 

review). 



1.8 User Management 

Windows Users 

The following Windows users are implemented by default in ExacTrac Dynamic: 

User Group Windows OS Permissions BL User Groups 

Administrator 

Administrator rights 

BL Service Administrator rights BL_ET_Service 

EmergencyUser 

ExacTrac Dynamic 


Power user rights 

BL_ET_Therapist 

BL_ET_TherapistRestricted 

Approver Power user rights BL_ET_Physician 

Physicist Power user rights BL_ET_Physicist 

• To use ExacTrac Dynamic, the user needs power user rights as a minimum. 

• Do not use accounts with administrator rights for treatment tasks. 

• Upon request, hospitals can have an emergency user/generic user account set up. It should 

only be used to access the system in case of an emergency. The hospital IT administrator is 

responsible for communicating the account information to the relevant employees. 

• Service tools and BL Service accounts are intended solely for Brainlab service and must not be 

used while treating patients. 

NOTE: Only members of the Windows user group Administrator can add, modify or delete user 

accounts. The Administrator account is preconfigured by Brainlab support and cannot be deleted. 

If your hospital needs to designate additional roles of user rights other than the standardized 

roles, Brainlab support must add the roles. For further information, contact Brainlab support. 

Windows Login and User Logs 

• The Windows login defines the user rights for the password-protected ExacTrac Dynamic user 

login. The hospital is responsible for administration of passwords and user logins. 

• Every ExacTrac Dynamic user login and ExacTrac Dynamic patient opening and closing 

event is logged and saved in an encrypted log. To access this information, contact Brainlab 

support. 

• In case of a technical or clinical issue with ExacTrac Dynamic, the folder "Log Files" shall be 

zipped and provided to Brainlab support. 

• Manually lock any account that has not been used for more than three months, except for 

Brainlab service. It is recommended to check for unused accounts at least every six months. 

Configuring Rights and Passwords 

Users must access ExacTrac Dynamic with a personal user name and password. User accounts 

have varying permissions, divided into roles. Upon setup, Brainlab support will create the following 

standardized roles: 


User Management 

Role 

Task 

Treatment preparation 

Treatment 

Fusion approval 

X-ray calibration 

Camera calibration 

Template editor 

ET_SuperUser ✔ ✔ ✔ ✔ ✔ ✔ 

ET_Physicist ✔ ✔ ✔ ✔ ✔ 

ET_Physician ✔ ✔ ✔ ✔ 

ET_Therapist ✔ ✔ 

ET_TherapistRestricted 

✔ 

ET_Service ✔ ✔ ✔ ✔ ✔ ✔ 

When assigning rights to new users, adhere to the principle of least privilege (e.g., only assign 

rights that are needed). 

Your hospital IT administrator can configure selected users as registered users with: 

• Approval rights so that image fusion can be approved (e.g., physicians for billing purposes) 

• Calibration rights (e.g., for physicists) 

• Basic rights for standard users (e.g., such as therapists) 

NOTE: Personnel who are still in training are typically assigned ET_TherapistRestricted. 

Accessing Password Settings 

Only the hospital IT administrator can change or reset a password. 



1.9 Technical Requirements For ExacTrac Dynamic 

Preparation Application 

About the Technical Requirements 

The ExacTrac Dynamic Preparation Application can be installed on an independent, dedicated 

server provided by the hospital or one purchased from Brainlab. This allows preparation of patient 

data for treatment with ExacTrac Dynamic independent of the Treatment Workstation used for 

the ExacTrac Dynamic Treatment Application for treatment. 

NOTE: Brainlab does not permit the installation of ExacTrac Dynamic Preparation Application 

on platforms with third-party medical software installed. It cannot be excluded that ExacTrac 

Dynamic Preparation Application influences the third-party software, and vice versa. In this 

context, it is the user's responsibility to provide and identify suitable platforms fulfilling the given 

requirements for installing the software, and to verify that ExacTrac Dynamic Preparation 

Application is not affected by any third-party software installations or third-party software 

updates. 

If it is necessary to revalidate the ExacTrac Dynamic Preparation Application software, use the 

software revalidation instructions found in this user guide. This requires access to the patient data 

stored by the service DICOM Proxy. 

Preparation Server Requirements 

If installed on a physical server, the following hardware and operating system minimum 

requirements must be fulfilled: 

Minimum Server 

CPU 

Memory 

Storage space 

Graphics card 

Network connection 

Operating system 

Screen resolution 

8 cores, with at least 2.2 GHz (or comparable) 

16 GB (or more) RAM DDR3 

Minimum 200 GB (1 TB recommended) 

N/A 

100 Mbit/s, 1 Gbit/s recommended 

Windows Server 2016 



English OS language 

1920 x 1080 (or more) 

NOTE: For server configurations that do not fulfill these minimum requirements, it cannot be 

guaranteed that ExacTrac Dynamic Preparation Application runs as intended. 

Server Virtual Machines 

Brainlab supports virtualization environments with Citrix XenServer or VMWare ESXi as 

recommended technologies. 

For access via Origin Server, the Windows Server license as well as the RD Client Access 

Licenses (RD CALs) and the SSL certificates must be provided by the hospital IT. 

3D Graphics and Algorithms Acceleration 

In general, the software runs without GPU support. Nevertheless, workflow steps in which graphic 

display and 3D rendering functions are available (DRR display, VOI restriction) have limited 

rendering performance and slower user interface response. 


Technical Requirements For ExacTrac Dynamic Preparation Application 

Server Requirements 

The minimum requirements defined above for the described hardware also apply for the minimum 

hardware to run ExacTrac Dynamic Preparation Application. For virtual machines, at least 8 

CPU cores with a minimum of 2.2 GHz and 16 GB RAM shall be available. 

NOTE: ExacTrac Dynamic Preparation Application and the corresponding Patient Preparation 

Server shall not run on the same server together with other Brainlab Elements software. 

Contact Brainlab support for additional questions about minimum hardware requirements for the 

dedicated server. 

Revalidating Preparation 

Because ExacTrac Dynamic Preparation Application indirectly affects the treatment by setting 

treatment parameters before actual treatment, it is recommended to test the functionality by 

deliberately setting a parameter using the software and performing a phantom treatment with 

ExacTrac Dynamic to verify that all parameters are correctly transferred. 

This should be done after the first installation on third-party hardware or after any change to the 

third-party software environment (e.g., OS hotfixes or virus scanner definition files) or to any other 

software that might influence software performance. 

If ExacTrac Dynamic Preparation Application does not start or in the unlikely event that 

parameters are not transferred correctly, contact Brainlab support. 



1.10 Training and Documentation 

ExacTrac Dynamic Installation and Preplanning Information 

Only trained personnel are permitted to install and service ExacTrac Dynamic. For further 

information, contact Brainlab support. 

Brainlab Training 

Before using the system, Brainlab recommends that all users should participate in a training 

program held by a Brainlab representative to ensure safe and appropriate use. 

Supervised Support 

After a sufficient number of complete procedures have been successfully simulated, and following 

a rigorous quality assurance review, the system can be used in selected treatments. 

A Brainlab representative should be present at such treatments to provide medical staff with 

supervision and guidance where necessary. 

Numerical Values Used in This User Guide 

In this user guide, all values and parameters describing imaging performance use standardized SI 

units: metric, Gy, mm and Gy*mm 2 . 

With the exception of angular measurements (indicated by the ° symbol), all numerical values 

displayed by ExacTrac Dynamic are in millimeters (mm). 

Responsibility 

Warning 

This system solely provides assistance to the physician and does not substitute or replace 

the physician's experience and/or responsibility during its use. It must always be possible 

for the user to proceed without the assistance of the system. 

Only trained medical personnel may operate system components and accessory instrumentation. 

Reading User Guides 

This guide describes complex medical software or medical devices that must be used with care. 

It is therefore important that all users of the system, instrument or software: 

• Read this guide carefully before handling the equipment 

• Have access to this guide at all times 

Available User Guides 

Available user guides vary depending upon your configuration. If you have questions regarding 

the user guides you received, please contact Brainlab support. 

User Guide 

ExacTrac Dynamic Elekta Linacs Site Planning 

Manual 

ExacTrac Dynamic Varian Truebeam Linacs 

Site Planning Manual 

Description 

Installation and preplanning information and requirements 

for use with Elekta linacs 


for use with Varian Truebeam linacs 


Training and Documentation 

User Guide 

ExacTrac Dynamic Clinical User Guide (all 

workflows) 

ExacTrac Dynamic Clinical User Guide (ExacTrac 

Dynamic Surface workflows) 

ExacTrac Dynamic System and Technical 

User Guide 

Description 

• Software setup and shutdown instructions 

• Detailed instructions on available workflows 

• Information on the clinical use 




Detailed information on system setup, technical 

information on the system, specifications and 

compliances 

Additional Documentation 

For further information about X-ray components, see the following documents. 

Device Document Manufacturer 

Housing Data sheet "Housing B-130" Varian Medical Systems 

Tube 

Data sheet "G-892" 

(Varex Imaging Corporation only for the 

X-ray tubes) 

HV Cables 

Data sheet "CA1-type Connector" 

"L3-type cable" 

Claymount 

Collimator This user guide Brainlab 

Generator 

Operating instructions "EDITOR 

Hfe" 

Service manual "EDITOR Hfe" 

Spellman High Voltage Electronics 

GmbH (formerly K&S Röntgenwerk) 

Customer Acceptance Test 

The accuracy of the specific system being used is outlined in the customer acceptance test. 


CLINICAL OVERVIEW 

2 CLINICAL OVERVIEW 

2.1 Using ExacTrac Dynamic in a Clinical 

Setting 

About ExacTrac Dynamic 

Figure 3 

ExacTrac Dynamic is a system that is used to position and monitor patients at the isocenter of a 

linear accelerator for radiotherapy procedures. The system consists of both hardware and 

software elements and can be integrated with certain Elekta and Varian linacs. 

Key features of ExacTrac Dynamic include: 

• Preparing patient plans for treatment with ExacTrac Dynamic Preparation Application. 

• Prepositioning the patient and monitoring patient movement throughout planned treatment with 

ExacTrac Dynamic Treatment Application. 

• Surface tracking via a single ceiling-mounted structured light projector, two high-resolution 

cameras and a thermal camera to ensure that no patient movement is lost. 

• Multiple calibration tools and a Daily Check to verify that the system is working properly. 

This chapter describes features of the ExacTrac Dynamic medical device. Which features are 

available for your system depends on your configuration, equipment and licenses. For further 


Primary Operating Functions 

Schedule, prepare patient for patient positioning 


Using ExacTrac Dynamic in a Clinical Setting 

• Treatment-specific and patient-specific data is set via templates. The templates are predefined 

by the hospital and not considered as primary operation function. 

Patient prepositioning 

• The user moves the treatment couch with the patient into the approximate planned isocenter 

until the field of view of the surface tracking unit is reached. 

• From there, the operator shall position the patient according to the surface tracking unit. The 

(pre-)positioning of the patient can be done manually or by sending the shift from ExacTrac 

Dynamic to the couch. 

Define surface tracking area 

• The user defines a surface tracking area for the surface and thermal cameras that is monitored 

during patient treatment. 

• For surface-only and breath-hold workflows: The surface tracking area selection is done after 

final treatment positioning was performed. 

• For breath-hold treatments, a respiratory point is defined, which is used to generate the patient 

breathing signal. 

Patient positioning to the planned isocenter 

• For ExacTrac Dynamic: The user acquires a stereo oblique X-ray images pair to determine 

actual patient position. Then the user visually verifies an automatically performed fusion 

between the X-rays to the reference digitally reconstructed radiograph (DRR) or the implanted 

marker pattern. For the verification, the user uses various verification tools. 

• For ExacTrac Dynamic Surface the positioning is achieved with an external IGRT device 

(e.g., CBCT). With ExacTrac Dynamic, monitoring these POF is not relevant. 

• For breath-hold treatments: For X-ray acquisition, the patient is navigated into a breath-hold 

state. X-rays are acquired and it is verified that X-ray acquisition timing, patient surface position 

and X-ray quality is correct before proceeding to the X-ray correction. 

Patient motion monitoring during treatment 

• For ExacTrac Dynamic (full system): The surface tracking unit provides surface and thermal 

information inside the area of interest, the software system notifies the user in case motion 

occurs that is outside of tolerance. If the user enables it, the system also acquires automatic X- 

ray images via the X-ray sequence button. Then the user must decide if repositioning is 

necessary before continuing treatment. 

• For ExacTrac Dynamic Surface: The surface tracking unit provides surface and thermal 

information inside the area of interest, the software system notifies the user in case motion 

occurs that is outside of tolerance. Then the user must decide if repositioning based on an 

external device is necessary before continuing treatment. 

• For breath-hold treatments: The treatment beam is gated based on the patient breathing signal 

and the area of interest position. The treatment beam is only enabled if the patient is within a 

defined breath-hold state and the area of interest position is within a defined tolerance. X-ray 

images may be acquired manually within the breath-hold state to verify correct OAR position. 

Calibration 

• The user positions the calibration phantoms exactly at the isocenter and then calibrates the 

system to this selected isocenter. 

Daily Check 

• The user positions the calibration phantoms on the couch near the isocenter and the software 

then checks if the X-ray system is still in line with the surface tracking. 

IEC Axis Definitions 

Axis 

Point of origin 

(0,0,0) 

Z-axis 

(vertical) 

Function 

The linac isocenter is defined by the intersection of the gantry rotation axis 

with the couch rotation axis. 

The vertical axis that runs through the point of origin perpendicular to the 

couch top plane at a tilt angle of 0°. This axis is positive above the point of 

origin and negative below the point of origin. This axis is also known as the 

vertical axis, as it describes the vertical movement of the couch. 

NOTE: For Varian scales, this axis is inverted. 



Axis 

X-axis 

(lateral) 

Y-axis 

(longitudinal) 

Function 

The horizontal axis that runs through the point of origin perpendicular to the 

gantry rotation axis. When facing the linac from the foot of the couch, this axis 

is positive to the right of the point of origin and negative to the left. This axis is 

also known as the lateral axis, as it describes the lateral movement of the 

couch. 

The horizontal axis that runs through the point of origin parallel to the couch 

top plane at a tilt angle of 0°. When facing the linac from the foot of the couch, 

this axis is positive when moving towards the linac from the point of origin, 

and negative when moving away from the linac from the point of origin. This 

axis is also called the longitudinal axis, as it describes the longitudinal movement 

of the couch. 

ExacTrac Dynamic Display Coordinate System 

To provide the ExacTrac Dynamic patient positioning system with accurate information on the 

current patient position, a three-dimensional coordinate system consistent with IEC 61217 is used 

to describe the movement and angle of the couch and linac. Coordinates can be displayed in four 

different ways: 

• IEC 61217 CCW359 

• IEC 61217 CCW180 

• Varian Standard CW180 

• Varian IEC CW359 

The selected display of the coordinate system can be reviewed in ExacTrac Dynamic. Open the 

menu, go to Information and then select System. 

The display of the coordinate system can only be changed by Brainlab support. 

Variations in Displayed Coordinate System Values 

The position and angle indicators display patient coordinate system values in accordance with IEC 

61217. As soon as the table is rotated out of the default position, the values indicated by the 

patient coordinate system may differ from those indicated by the linac coordinate system. 


Using ExacTrac Dynamic in a Clinical Setting 

Figure 4 

No. 

1 

2 

3 

4 

5 

6 

Description 

Couch vertical (Z) 

Couch longitudinal (Y) – Seen from above 

Couch lateral (X) – Seen from above 

Couch rotation (Yaw) – seen from above 

Couch Pitch 

Couch Roll 



Couch Fixed Coordinates 

Figure 5 

The coordinate system rotates with the couch. This means the tolerances remain the same for 

rotated couch positions (i.e., lateral means patient left-right, longitudinal means patient head-feet). 

Rotational Angles 

• Rotation around the vertical axis results in a couch angle. 

• Rotation around the longitudinal axis results in a longitudinal tilt angle or roll angle. 

• Rotation around the lateral axis results in a lateral tilt angle or pitch angle. 

• The couch angle is displayed in ExacTrac Dynamic in accordance with the scale used by your 

linear accelerator. The default position may therefore be 0° or 180° and the positive rotation 

may be clockwise or counter-clockwise. The system is customized to match your linac during 

acceptance (e.g., clockwise with couch at 180° for standard position (CW180)). 


ExacTrac Dynamic Integration with Specific Linacs 

2.2 ExacTrac Dynamic Integration with Specific 

Linacs 

ExacTrac Dynamic Integration 

ExacTrac Dynamic can be integrated into different linac environments. For the different linac 

types, specific requirements must be considered. 

Ensure that other third-party surface devices are inactive (e.g., no emission of light, no active 

interference with workflow) during treatments with ExacTrac Dynamic. 

Do not use two or more systems simultaneously during the same treatment fraction. Only one 

system may be active during one fraction and no cross-system workflows are allowed. 

Interfaces of Specific Linacs 

Depending on your system configuration, you may have one of the following interfaces. 

For TrueBeam linacs, ExacTrac Dynamic uses the MMI (Motion Management Interface). MMI 

interaction between the MMI device and TrueBeam is carried out via the underlying ADI (Auxiliary 

Device Interface) and EXGI (External Gating Interface) protocols. 

Name Purpose Description 

ADI 

EXGI 

XML-based TCP protocol 

Protocol for gating devices 

• Obtains all non-realtime status from TrueBeam 

through the ADI. 

• Receives patient ID, plan ID and planned/actual 

axis positions. 

• Sends couch shifts and beam authorization 

through the ADI. 

• Gating signal: The gating device requests a beam 

hold through the gating signal. 

• Interlock signal: The gating device requests a 

beam interlock through the interlock signal. 

• RS-422 interface: TrueBeam sends accumulated 

dose, beam state, pre-beam-on check request, 

plan participation, and detected gating and interlock 

signal states. TrueBeam receives plan participation, 

pre-beam-on check state, and redundant 

gating and interlock signal states. 

Do not use beam authorization by ExacTrac Dynamic via ADI as a safety feature to ensure 

correct patient positioning before treatment. For any treatments performed with ExacTrac 

Dynamic, always verify that ExacTrac Dynamic confirms the target position is in tolerance. 

The patient position icon must indicate that the patient isocenter is in the planned treatment 

position. Do not treat the patient if the patient position icon shows the patient out of tolerance. 

For Elekta integrations, the following interfaces may be used. 


iGUIDE GMI Generic measurer interface 

ExacTrac Dynamic can connect to the interface for 

automatic 6DoF positioning using iGUIDE. 

Response 

iCOM Vx 

MOSAIQ 

32bit DLL gating interface 

Internal communication 

protocol (read only) 

Patient positioning systems 

interface 

ExacTrac Dynamic can gate the treatment beam 

and enable treatment beam hold for X-ray monitoring. 

ExacTrac Dynamic can read linac machine parameters. 

ExacTrac Dynamic can connect for synchronized 

workflow control and automatic 3D positioning using 

the Elekta Precise Table. 




Linac HW 

Signal Interface 

CITB board with beam inhibit, 

MV beam on, and other 

linac HW signals 

ExacTrac Dynamic can connect to linac signals. 

Varian Integrations 

• Hyper ARC treatments on TrueBeam are not supported with ExacTrac Dynamic. 

• Unplanned treatment on TrueBeam is not supported with ExacTrac Dynamic. 

• Triggered acquisitions of MV Port Film fields on TrueBeam is not supported with ExacTrac 

Dynamic. 

• The automatic positioning procedure is provided by the ADI positioning dialog. ExacTrac 

Dynamic is required to authorize every treatment on the TrueBeam linac using ADI. Ensure 

that ExacTrac Dynamic is always running when treating patients on linac. 

• Automations are not supported with TrueBeam linear accelerators as not all ADI events are 

transmitted for subsequent beams. 

NOTE: Automations is a functionality on TrueBeam that allows a one-click delivery of several 

treatment beams in one go. 

Elekta Integrations 

• ExacTrac Dynamic supports some consolidated field sequencing (CFS) plan modalities. 

• ExacTrac Dynamic supports Multi Arc CFS plans from the Monaco TPS on Elekta linacs: 

- Including 2-4 arcs grouped in one field/beam. 

- Different start-stop angle within the multi-arc beam (turning angles have to be the same). 

• Other CFS plan modalities such as multiple static fields in one arc are not supported. 

Response System Limitations 

Event 

Duty cycle restrictions 

VMAT delivery 

technique restrictions 

Response error 

handling 

Response with 

multiple clients 

Limitation 

For safety reasons, ExacTrac Dynamic prevents Beam On less than three 

seconds after the previous Beam On. 

NOTE: If you do not include this function, the PPMS can cause an incorrect 

dose. 

If radiation delivery of less than two seconds occurred, a warning message is 

displayed. A radiation delivery of less that two seconds can cause gantry position 

errors and an incorrect dose. For further information, refer to the PPMS 

manufacturer's instructions for use. 

If ExacTrac Dynamic detects a relay fault of the Response, a beam inhibit is 

set by ExacTrac Dynamic. For further actions, refer to the Elekta linac troubleshooting 

guide. 

Response is not a multi-client interface and needs to be manually connected 

via USB to the system that is used for treatment. If you want to use Exac- 

Trac Dynamic for positioning and monitoring, keep the Response USB cable 

connected. 

If you want to use Response with another system (and not with ExacTrac 

Dynamic), reconnect the USB to the other device and put ExacTrac Dynamic 

in stand-by mode. To do this, ensure that you are in the treatment 

workflow and that Treatment is running. Patients that are not planned to be 

treated with ExacTrac Dynamic will be authorized in this state and the 

beam-inhibit interlock will be cleared. 


ExacTrac Dynamic Integration with Specific Linacs 

Event 

Limitation 

If a fast gating condition occurs, treatment is held and a message box is displayed 

by ExacTrac Dynamic. 

Fast gating condition 

For further information, see the linac manufacturer's instructions for use. 

NOTE: To avoid beam termination on the linac, the condition must be resolved 

within two minutes. The user can prevent the beam termination if they 

select INTERRUPT on the FKP within the two minute interval. 

If the fast gating condition message appears, always check the root cause of 

the error before acknowledging the error with OK because doing so will resume 

beam delivery immediately. Fast gating condition could be resolved by: 

• Checking the patient position 

• Guiding the patient into the correct breathing level (in Breath-hold X-ray 

Positioning with Surface Monitoring (Manual X-rays)) 

• Modifying tolerances, if needed 



2.3 Positioning with Varian or Elekta 

Integrations 

Depending on your configuration, you may need to adjust the positioning and monitoring steps as 

described in the upcoming pages. 

Using the Console or Pendant to Activate Couch Motion 

Once the shift has been sent to the linac, use the console or pendant to activate couch motion. 

NOTE: Based on the “tolerance table” configured on the linac, some motions must be enabled 

from within the treatment room, such as when couch rotations or large correction shifts are 

involved. 

For details regarding the console or couch pendant, as well as for general safety precautions, 

refer to the system documentation provided with your accelerator. 

Automatic Couch Motion for Elekta Linacs 

With Elekta linacs, ExacTrac Dynamic uses different interfaces for positioning. 

For prepositioning, the MOSAIQ PPS interface is used for sending 3DoF shifts to the Precise 

Table. 

Automatic Couch Motion for Varian TrueBeam Linacs 

With TrueBeam linacs, ExacTrac Dynamic uses the auxiliary device interface protocol (ADI) to 

send couch move requests to the treatment application of the Varian linac. 

The automatic positioning procedure is guided through the couch movement dialog. 

Using the iGUIDE Reference Frame 

The iGUIDE Reference Frame must be mounted on the table if HexaPOD will be used and 6DoF 

shifts should be applied. 

It is not recommended to do manual input in iGUIDE with the values displayed in the ExacTrac 

Dynamic Treatment Application Send Shift dialog. If the connection between both systems is 

lost, first reestablish the connection, and then resend the shifts. 

For further information, see the iGUIDE manufacturer's instructions for use. 

The iGUIDE Reference Frame should be placed in a way that it does not interfere with the 

ExacTrac Dynamic field of view of surface tracking. Ensure that it is possible to select a tracking 

area on the patient for ExacTrac Dynamic surface tracking that reflects the movement of the 

treated target area but that the reference frame is positioned within the tolerances given by 

iGUIDE. 

For further information regarding the placement of the iGUIDE Reference Frame, see the 

HexaPOD evo RT System and iGUIDE instructions for use. 


3 GETTING STARTED 

3.1 Preparing for Treatment 

Treatment Preparation 

This chapter provides general information about treatment preparation, including setting up the 

patient on the couch, using the iGUIDE reference frame (if required) and technical considerations 

for scanning patients. Which features are available for your system depends on your 

configuration, equipment and licenses. For further information, contact Brainlab support. 


GETTING STARTED 

3.2 Prepositioning Contour 

About the Prepositioning Contour 

The Prepositioning Contour is used for the initial automatic prepositioning step of the treatment 

workflow. If a plan lacks a Prepositioning Contour, it does not prevent patient prepositioning 

and/or treatment, but it is recommended to facilitate the initial prepositioning. 

Prepositioning Contour Setting 

• The value of the Prepositioning Contour setting is determined during installation, and 

generally matches the contour most frequently used in the clinical setup. 

• You can set a list of the most used prepositioning contours. 

• If more than one prepositioning contour matches the contours of the plan, then none of them 

will be selected. Prepositioning needs to be performed manually. 


About Patient Positioning 

3.3 About Patient Positioning 

General Positioning Recommendations 

• Ensure that the patient is not positioned near any metal components in the couch top. 

Otherwise, these components could be included as artifacts in cone-beam CT correction and 

verification images. 

• With the patient positioned, check all intended or planned movements before leaving the 

treatment room. Perform a verification before starting the actual treatment to ensure that the 

patient is still in final treatment position. 

• In the breath-hold workflow, patient positioning starts in the free-breathing position. 

Automatic Couch Positioning 

When performing automatic couch positioning from the control room, observe the positioning 

process carefully on the video monitors and follow the positioning indicators on the screen. If 

couch motion is excessive (e.g., during patient prepositioning or because the couch clearly moves 

a substantially larger distance than the required shift), perform the positioning process from within 

the treatment room only. 

It is the hospital's responsibility that all used systems are calibrated to the linac isocenter. Within 

the scope of the measuring accuracy, minor inaccuracies during the different calibration 

procedures can occur. 

Warning 

Always ensure that patient is positioned the same during CT scanning and treatment. This 

includes the positioning method, patient posture and orientation as well as patient fixation. 

Manual Positioning 

If surface matching fails during prepositioning (e.g., due to a blanket or cover), preposition the 

patient manually. 

NOTE: Because accuracy is very important for the Breath-hold External Positioning with 

Surface Monitoring workflow, manual prepositioning is not recommended. Use the legend to aid 

you with prepositioning instead. 



3.4 Room Lighting Conditions 

Adjusting Room Lighting Conditions to Prevent Tracking Loss 

In very rare cases, tracking can be lost due to room lighting conditions. 

Radiation therapy bunkers with illuminated ceiling displays may have an influence on the 

structured blue light of the surface camera projector (with a wavelength of 459 nm) that is used 

during tracking. The magnitude of potential interference depends on the color temperature 

(spectral composition) and intensity of the room light. 

To reduce potential interference between the room light and the structured blue light of the 

projector, consider the following lighting recommendations in case tracking issues are 

experienced: 

• Reduce light intensity. 

• Reduce blue light components of bunker illumination and choose a warm color temperature (if 

possible). 


Avoiding Collisions 

3.5 Avoiding Collisions 

About Avoiding Collisions 

• Remote couch motion should not be used if accessories that limit the clearance between 

patient and gantry are used. Accessories such as conical collimators lead to a higher collision 

risk so that the automatic couch motion should only be enabled from inside the treatment room. 

• If you suspect a collision may occur, stop motion enabling immediately. Release the motion 

enable buttons on the console or pendant in the treatment room. 

• If a dry run is necessary to ensure there is no risk of collision, make sure to perform this dry run 

in the final treatment position (e.g., after the shift has been applied). 

• Tell patients to remain on the treatment couch and not move until a clinician tells them that it is 

safe to do so. 

• Ensure that there is no collision with the patient or patient fixation/tracking accessory and any 

part of the linac or linac accessories during patient positioning. 

NOTE: When the Patient Feedback System mirror is used with a breath-hold workflow, it may 

introduce an additional collision risk. 



3.6 Technical Considerations 

Scan/RT Plan Requirements 

Requirement 

Description 

Supported number of 

slices (with each 512 x 

512 pixels) 

The number of slices used has an influence on software performance, 

especially regarding the time required for X-ray fusion. For scans with 

up to 900 slices (512 x 512 matrix), the software usually requires less 

than 5 seconds for X-ray to DRR fusion. 

Slice distance 

Gantry tilt/angulation 

Scan direction 

Treatment position 

Image/pixel size 

Table height 

Image representations 

DICOM Image Transfer 

Syntax 

Maximum 5 mm, equidistant. 

Not supported. 

• Cranial to caudal 

• Caudal to cranial 

Head first or feet first, prone or supine. 

Do not change during scan. 

Do not change during scan. 

Gray scale (one channel) with 1 sample per pixel and 16 bits allocated. 

See DICOM Conformance Statement for Origin Data Management. 

Matrix size 512 x 512 x 900 

Outer contour 

Outer contour object (patient contour) is exported with a name corresponding 

to the Prepositioning Contour setting list (set by Brainlab 

support) in the RT structure set, otherwise the user must preposition 

manually. This is applicable for all workflows. 

For breath-hold workflows, the outer contour name must correspond to 

the Prepositioning Contour name expected by ExacTrac Dynamic. 

Warning 

Always select the actual patient orientation and patient direction for the CT scan. Storing 

the wrong direction/orientation may result in an incorrect patient position. 

Notes 

Depending on the rotational correction required, a significant couch top tilt may occur during 

positioning. To prevent the patient slipping off the couch, ensure that they are securely positioned, 

and that non-secure objects, such as towels, are not placed between the patient and the couch 

top. 

Warning 

Brainlab strongly recommends the use of a patient fixation device to restrict patient 

movement. 

Warning 

Ensure that all accessories are securely mounted. 

Warning 

Tell patients to not move and remain on the treatment couch until a clinician tells them that 

it is safe to do so. 


Technical Considerations 

Treatment Parameters 

ExacTrac Dynamic operation was tested to be fully operational with the following treatment 

parameters. If the treatment parameters are exceeded, it is recommended to test the parameters 

first before restarting Treatment, if applicable. 

Treatment Parameter 

Maximum MU/s 

Maximum MU/beam 

Maximum MU/fraction 

Maximum beams/ 

patient 

Maximum patients in a 

row 

Maximum treatment 

length 

Maximum patient data 

size 

Maximum number of 

slices 

Maximum number of 

OOT events 

Limitation 

Patients can be treated with up to 100 MU/s (monitor units per second, 

equals 6000 MU/m) 

Patients can be treated with up to 10,000 MU/beam (monitor units per 

beam) 

Patients can be treated with up to 50,000 MU/fraction (monitor units per 

fraction) 

Patients can be treated with up to 50 beams per patient 

40 patients can be treated in a row without restart 

Patient sessions may last up to two hours 

Patients can be treated with a data set (RTPlan) of up to 495 MB 

Patients can be treated with a data set of up to 900 slices (with 512 x 

512 pixels per slice) 

Patients can be treated with up to 120 out-of-tolerance events 

NOTE: An out-of-tolerance event is defined as the point in time when a patient is within the 

defined limits in all translations and rotations and then moves so that at least one translation or 

rotation violates the defined limits. 



3.7 Patient Data Prerequisites 

Prerequisites 

Warning 

Never manually modify any patient data. This could lead to incorrect patient treatment. 

Warning 

Do not access patient data specific to ExacTrac Dynamic with software other than 

ExacTrac Dynamic. 

Warning 

Ensure that the isocenter and planning data used are from the same treatment plan on the 

linac and on ExacTrac Dynamic. Isocenter will always be shown as DICOM coordinates. 

Warning 

To ensure subsequent positioning accuracy, verify the level of artifacts in the CT data set 

are as low as possible. If there are significant motion artifacts, the patient must be 

rescanned. 

Warning 

Artificial CT scans are not suitable for positioning or monitoring since these lead to 

incorrect image fusion results. 

Warning 

CT scans acquired using a contrast agent are not suitable for positioning during treatment 

since these lead to incorrect image fusion results. 

Warning 

Ensure that the CT scan contains appropriate anatomical information for patient 

positioning. 

Warning 

Using CT data sets that differ from the recommended format (in particular those that do not 

conform to recommended data volume), can lead to reduced performance or accuracy. 

NOTE: ExacTrac Dynamic cannot open patient data created with predecessor versions of 

ExacTrac (e.g., 5.X or 6.X). Previous versions of the Prep & Review software are also not 

compatible. 


4 SYSTEM STARTUP AND 

SHUTDOWN 

4.1 About System Startup and Shutdown 

About This Chapter 

This chapter provides general information related to the ExacTrac Dynamic system. Which 

features are available for your system depends on your configuration, equipment and licenses. 

For further information, contact Brainlab support. 

About Startup 

This section describes how to correctly start up the system as well as the background services. 

How to Use the Console to Start the System 

By default, use the ExacTrac Console to start the system. 

Step 

1. 

2. 

Ensure that the orange standby indicator on the console is lit. 

Press the System ON button (I) on the console. The green indicator light should turn on 

and remain lit. 

Booting Up the Treatment Workstation 

The Treatment Workstation starts up automatically after the system is powered up. Booting up 

the Treatment Workstation separately is not required. 


SYSTEM STARTUP AND SHUTDOWN 

How to Power Up the System Via the Power Distribution Unit 

By default, use the ExacTrac Console to power up the system. System startup via the Power 

Distribution Unit (PDU) is for troubleshooting purposes only. 

Step 

1. 

2. 

In the PDU, set all circuit breakers to the ON position. 

Ensure that the red indicator of the PDU STOP button is lit (i.e., the start mode switch 

must be in the CIU position). 


About System Startup and Shutdown 

Step 

3. 

To start the system, press the START button of the PDU. Ensure that the START button's 

green indicator and the CIU POWER blue indicator are continuously lit. 

Auto-Start Timer 

The Auto-Start Timer included in the PDU automatically turns on the system so that the camera 

reaches temperature equilibrium state B by a predetermined time, without the need to manually 

turn on the system. For further information, see the related links below. 

The start time must be set to at least one hour before planned clinical use. If the timer is 

programmed to start the system automatically, you can shut down the system every day after use 

(e.g., to save energy). 

Setting a daily system startup time helps address implications during clinical use due to 3D 

Camera system warm-up (e.g., failing the Daily Check). 

Related Links 

About 3D Camera Warm-Up on page 138 



4.2 Starting the ExacTrac Dynamic Software 

Background 

Once you have booted the ExacTrac Dynamic system, and accessory components such as the 

camera and Treatment Workstation are running, you can start the Preparation or Treatment 

software. 

Ensure that any external devices (e.g., a USB flash drive or USB hard drive) has been removed 

from the Treatment Workstation prior to patient treatment. 

How to Start the Software 

Step 

1. To start the software, select Brainlab Elements. 

Content Manager opens. 

2. Select a workflow under ExacTrac Dynamic (e.g., Treatment). 

3. When starting Treatment, the following actions are performed. ExacTrac Dynamic system 

connects to: 

• Xray Service for configurations with X-ray capability 

• The Gating Service: Either EXGI Service for Varian linac integrations or Elekta 

Gating Service for Elekta linac integrations 

• Varian Service or Elekta Service (including iCOM Service) 

NOTE: The services start automatically during boot up of the ExacTrac Dynamic system. 


Background Services 

4.3 Background Services 

Background Services for Software 

Figure 6 

The background services must be running before starting the ExacTrac Dynamic software. 

Services start automatically during boot up of the system. This can take up to a few minutes. 

Once the services are started properly, ExacTrac Dynamic is ready to be started. 

You can check the status of any service relevant to ExacTrac Dynamic by accessing the 

Windows Services tab of the Task Manager. 

Background Services for Integrations 

Some services that appear under the Windows Services tab of the Task Manager are relevant for 

ExacTrac Dynamic integrations. 

Varian-Relevant Services 

Xray Service 

Varian Service 

EXGI Service 

Elekta-Relevant Services 

Xray Service 

Elekta Service 

Elekta Gating Service 

iCOM Service 



Background Services Failure 

Figure 7 

If ExacTrac Dynamic is running when a failure occurs in the background services, a warning 

dialog is displayed. In most cases, the corresponding service auto-recovers and the dialog 

disappears. 

If it does not, you can restart the disconnected service by selecting the button to restart it. 

If the problem continues, shut down and restart the system. 

If the issue persists, contact Brainlab support. 


Restarting the System 

4.4 Restarting the System 

How to Restart the System 

Figure 8 

Step 

1. From the menu, select Quit Treatment App. 

2. Shut down Windows. 

3. Press System Off (O) on the console to power down ExacTrac Dynamic completely. 

4. Restart the system by selecting either: 

• System On (I) on the ExacTrac Console. 

• START on the Power Distribution Unit (System startup via the Power Distribution 

Unit is for troubleshooting purposes only.). 



4.5 Shutting Down the Software 

Background 

Once patient treatment has been completed, the software can be shut down. 

If the Windows user changes, the user must close the ExacTrac Dynamic application before 

locking Windows. Otherwise, other users will be able to log in to Elements, but will not be able to 

use ExacTrac Dynamic. 

If the system is shut down before the software is closed, data can be lost. 

How to Close the Patient File 

Step 

To close the current patient file, close the patient on the linac. 

How to Exit the ExacTrac Dynamic Software 

Before shutting down the system, you must exit the ExacTrac Dynamic software correctly. 

Step 

1. Open the menu. 

2. Select Quit Treatment App. 

3. An exit prompt is shown. 

4. Select Yes to close the software. 


Shutting Down the System 

4.6 Shutting Down the System 

About Shutting Down the System 

By default, use the ExacTrac Console to shut down the system. 

For optimum system performance and reduced power consumption, Brainlab recommends 

shutting down the system every day after treatment ends (if the automatic start function is 

enabled). 

Emergency Stop/Off 

In the event of an emergency, push the emergency off switch installed in the room. 

How to Shut Down the System 

Step 

1. Shut down the Windows operating system by selecting Shut Down in the Start menu. 

2. Wait until the Treatment Workstation shuts down and the monitor goes black. 

3. 

1 

Turn off the system power by pressing the System Off button 1 on the ExacTrac Console 

for three seconds. The orange standby LED will flash during this time. 

• When the green POWER LED turns off, this indicates that system mains power is 

turned off. 

• As long as the system is OFF, the orange standby LED remains ON (indicating standby 

voltage 24 V DC). 

How to Power Down the System Via the Power Distribution System 

By default, use the ExacTrac Console to shut down the system. System shutdown via the Power 

Distribution Unit is for troubleshooting purposes only. 



Step 

1. 

2. 

Press STOP on the Power Distribution Unit. 

The green and blue indicators turn off. 

Only the red indicator remains ON (indicates 24V DC Standby power). 

Additional Notes on Shutdown 

• The circuit breakers of the Power Distribution Unit should remain always ON. Otherwise, the 

daily automatic start function cannot start up the system. 

• If you prefer to always keep the system on, the Treatment Workstation must be restarted daily 

before treatment. Otherwise, its performance may be affected. 


Overview of Available Applications 

4.7 Overview of Available Applications 

About the Applications 

• This user guide includes a description of available ExacTrac Dynamic applications. Which 

applications are available with your system depends on your configuration, equipment and 

licenses. 

• All of the applications are described in the ExacTrac Dynamic Clinical User Guide 

Preparation and Treatment Applications 

Option 

ExacTrac Dynamic Preparation 

Application 

ExacTrac Dynamic Treatment 

Application 

Description 

Select a plan (if one did not load automatically), review plan settings 

and confirm a patient plan in this application. 

Select a template with predefined treatment settings, which can be 

reviewed and adjusted to match patient-specific needs. 

From this point forward in this user guide, ExacTrac Dynamic 

Preparation Application will be referred to as Preparation. 

Perform positioning and monitoring for multiple workflows. Adjust 

settings, position the patient and monitor treatment from this application. 


Treatment Application will be referred to as Treatment. 

Quality Assurance Tools - Surface 

ExacTrac Dynamic offers several primary and secondary quality assurance and calibration tools. 

Which tools are available is license dependent and based on your system configuration. 

Application 

Thermal to 3D Camera 

Calibration 

Isocenter Calibration Surface 

Daily Check Surface 

Surface Tracking QA 

Description 

Establishes a relative calibration between the Thermal Camera 

and the 3D Camera using a heated phantom. 

Calibrates the surface tracking system to the linac coordinate system 

and isocenter. 

Perform at least once each day to verify that: 

• The system setup geometry has not changed. 

• The phantom's position corresponds with the saved isocenter 

position. 

Quality control test to ensure optimal system performance of surface 

tracking system. 

Additional Tools - Surface 

Application 

Template Editor 

Repeat Export 

Archive/Delete Patients 

Description 

Creates or adapts the templates (e.g., to use hospital-specific settings). 

Re-exports the patient treatment report to the R&V system. 

Exports or deletes local patient data. 


PREPARATION 

5 PREPARATION 

5.1 Using the Preparation Application 

Using Preparation 

This user guide describes all ExacTrac Dynamic features. Which features are available for your 

system depends on your configuration, equipment and licenses. The following pages describe 

typical preparation workflows for ExacTrac Dynamic as well as information regarding the usage 

of specific linacs. 

Use Preparation for all workflow types to: 

• Select a patient plan 

• Assign a template 

• Review and adjust patient settings 

How to Prepare a Plan 

Step 

1. Select Preparation from the Content Manager. 

Plan Selection opens. 

2. Select a plan (if one did not load automatically). 

3. Select Load. 

4. Select a template from the list and select Confirm. 

5. Review template settings and adjust if necessary. 

6. Select Finish Patient Preparation to proceed. 


Using the Preparation Application 

Reviewing Plan Settings 

1 

2 

Figure 9 

No. 

1 

2 

Description 

Category of plan settings (e.g., Patient Position Preferences) 

Options and information about this step 

Once the patient plan is imported, review and adjust individual settings. Scroll down or select from 

the menu. Always review settings carefully before making changes. 

Warning 

The patient settings determine several parameters that directly affect patient positioning. 

Brainlab strongly recommends that these settings are defined by the physician and/or the 

physicist who created the treatment plan. 

Warning 

When using multiple ExacTrac Dynamic systems for a patient treatment, ensure that 

patient settings are adjusted according to the used system for each fraction. 

Warning 

Always verify that selected system settings match with the present (linac) system (e.g., the 

possibility to correct for pitch and roll). 


PREPARATION 

5.2 Plan Selection 

Selecting a Plan 

1 

Figure 10 

If a plan does not load automatically, the first step in the Preparation workflow is to select and 

load a patient plan. Select the arrow 1 to view all plans that have been pushed from the hospital's 

R&V system to ExacTrac Dynamic. 

Warning 

Do not load new patient when current patient is still in the treatment room. 

NOTE: Always prepare patient data in Preparation before beginning treatment with Treatment. 

How to Select a Patient Plan 

Step 

1. Start Preparation in the Content Manager. 

The Plan Selection page opens. 

Select the arrow in the upper right corner to view available plans. 

2. Select the appropriate option: 

• Not Prepared: Plans that have been imported but not prepared for treatment in Exac- 

Trac Dynamic. 

• Prepared: Imported plans that have been prepared for treatment, but not yet treated. 

• Treated: Patient plans that have already been treated. 

• All: All imported plans (except failed plans). 

• Import Failed: Plans that did not import successfully. 

3. Select the required patient plan. 

4. To view more information about a specific patient plan, select the arrow. 



Plan Selection 

If the Plan is Open on Another Workstation 

Figure 11 

ExacTrac Dynamic warns you if any plan of the patient you just opened is already open on 

another workstation. 

Options 

Close the patient plan by selecting: 

• Cancel & Auto-authorize (in Treatment) 

• Return to Patient Plan Selection (in Preparation) 

Open the patient plan and work on it 

If you open patient plan to work on it, be aware that the last changes made to the plan overwrite 

any previously made changes. This means either you overwrite the changes made by your 

colleague, or your colleague overwrites your changes. 

NOTE: ExacTrac Dynamic does not warn you again at the time the plan is saved. 

If Someone Opened the Plan you are Working on on Another Workstation 

Figure 12 

ExacTrac Dynamic warns you if you are preparing a patient plan and someone else opens any 

plan of the same patient on another workstation. 

Options 

Close the patient plan by selecting: 

• Cancel & Auto-authorize (in Treatment) 

• Return to Patient Plan Selection (in Preparation) 

Continue working on the patient plan 

If you continue to work on the patient plan, be aware that the last changes made to the plan 

overwrite any previously made changes. This means either you overwrite the changes made by 

your colleague, or your colleague overwrites your changes. 

NOTE: ExacTrac Dynamic does not warn you again at the time the plan is saved. 


PREPARATION 

Opening the Patient Plan on the Same Workstation in Another Application 

Figure 13 

It is not possible to open the same patient plan on the same workstation in two applications 

simultaneously (e.g., Treatment and Preparation). 

You must close the patient plan in one application before you can open it in the other. 


Template Selection 

5.3 Template Selection 

Selecting a Template 

The next step is to select a template. Settings are applied to the patient plan based on your 

selection. 

Warning 

During patient treatment plan preparation, always verify that the template selected best 

suits the needs of the patient. 

How to Select a Template 

1 

Figure 14 

Step 

1. Select a template from the list displayed on the left side. 

Plan Settings Preview is displayed. 

2. Review the settings. 

3. If this is the correct template, select Confirm 1. 

NOTE: If you decide the template is not suitable for your planned treatment, select a different 

template. 


PREPARATION 

5.4 Template Editor 

Using the Template Editor 

ExacTrac Dynamic provides a set of master templates. These are the basis when creating a 

custom template. 

After installation but before using the software for the first time, you must define at least one 

custom template. Otherwise there will be no template to choose from in Preparation. 

If you have sufficient user rights, you can modify or create custom templates (e.g., to establish 

hospital-specific settings) using the master templates as a starting point. 

Settings are applied to the patient plan based on your selection. 

How to Create a New Template 

1 

Figure 15 

Step 

1. From the Content Manager, open Template Editor. 

2. Select Add Template. 



Step 

3. 

Select a master template that is similar to your requirements. 

Select Create new template. 

4. 

A pop-up opens. 

5. Enter a unique name for the new template and select Save. 

The number of characters are limited and you may only use lowercase and uppercase letters 

and the numbers 0 to 9. If you attempt to use unacceptable characters, a pop-up is 

displayed. 

6. Select OK. 

The new template is added to the list of templates. 

How to Edit an Existing Template 

To edit the standard settings for one of the custom templates (e.g., to use hospital-specific 

settings), open Template Editor. 

NOTE: To change template settings, you must have sufficient user rights. 

NOTE: When upgrading to ExacTrac Dynamic 2.0, all previously stored custom templates will be 

lost and new custom templates must be created based on the new master templates available in 

ExacTrac Dynamic 2.0. For further information, contact Brainlab support. 


PREPARATION 

NOTE: Automatic beam control is selected by default for every master template provided by 

Brainlab. It is recommended to keep this feature selected when designing templates, as well as 

for plan preparation. In case the automatic beam control is turned off, it is not the responsibility of 

ExacTrac Dynamic to stop the beam if the patient moved outside the defined patient thresholds. 

Step 

1. From the Content Manager, open Template Editor. 

2. The Template Editor page opens. Select the template you want to edit. 

3. 

Adjust settings as required. 

When you are finished, you have two options: 

• Select Apply to save the changes under the current template name. 

• Select Save As to save your changes under a different template name. 

4. 

If you select Save As, a pop-up opens. 

Enter a unique name for the new template and select Save. The new template is added to 

the list of templates. The number of characters are limited and you may only use lowercase 

and uppercase letters and the numbers 0 to 9. 

You can also Cancel. 

5. Open the Menu and select Quit Template Editor to return to the Content Manager 

workflow selection. 


Treatment Plan Settings 

5.5 Treatment Plan Settings 

Adjusting Treatment Plan Settings 

Most treatment settings for patient plans can be changed in Preparation and via the menu in 

Treatment. The system informs you if a setting cannot be changed in the open application. 

The following pages are arranged in the order they appear in Preparation. They describe plan 

information and indicate where changes can be made, as well as for how long a change applies. 

Depending on where a setting is changed, a setting change may remain in effect: 

• For all patient sessions (e.g., the lifetime of the plan) 

• For the current session 

• For the current couch angle (PSA) of all patient sessions 

• For the current beam 

For example, any threshold set during Preparation can be changed during treatment and 

monitoring, but if the patient plan is closed and reopened in Preparation, the threshold will revert 

to what was set during plan preparation. 

Notes 

Warning 

The patient settings determine several parameters that directly affect patient positioning. 

Brainlab strongly recommends that these settings are defined by the physician and/or 

physicist who created the treatment plan. 

Warning 

Always review the selected thresholds and settings carefully during preparation. 

Warning 

When using multiple ExacTrac Dynamic systems for patient treatment, ensure that patient 

settings are adjusted according to the used system for each fraction. 

Warning 

Always verify that selected system settings match the present linac system (e.g., the 

possibility to correct for pitch and roll). 


PREPARATION 

Page Overview: Preparation 

1 

2 

3 

4 

Figure 16 

Although different buttons or tools may be available based on your workflow selection or workflow 

step, the page layout in Preparation follows this basic design. 

No. Component Description 

1 Menu Open to quit the application or return to patient selection. 

2 

3 

Current workflow step indicator 

View area 

Shows the current workflow step (e.g., Plan Settings 

Adjustment). 

Information and options about the current group of settings. 

4 Workflow guidance Displays information about step and available options. 



General 

Figure 17 

This category of settings determines the general treatment indication, as well as the general 

workflow and required system positioning technique. 

Heading Setting Description 

ExacTrac Dynamic Workflow 

Breathing Management 

Positioning Device 

Surface Only 

Breath-hold 

External (e.g. CBCT) 

Only surface modality is used within 

the workflow. 

Activate to treat breath-hold workflows. 

ExacTrac Dynamic accepts the patient 

position from an external positioning 

device (such as CBCT). 

The first time you open a patient plan in Preparation, you must select from one of the treatment 

templates appropriate for the indication. 

• Your template selection will display settings that are suitable for that treatment indication. 

• The selected template remains valid for the lifetime of the patient plan. 

Select how the patient will be positioned. The option is applied to the plan for the lifetime of the 

plan. 

NOTE: With Elekta integrations using external positioning workflows, it is only possible to 

reposition the patient using ExacTrac Dynamic with 3DoF. 

Beam Hold Settings 

Setting 

Beam Hold Control 

Description 

Allows the software to hold the beam if the patient is out 

of tolerance. The setting in Preparation is applied to all 

treatment sessions and beams. Changes made via the 

Menu apply to the current beam only. 


PREPARATION 

Setting 

Surface out of tolerance delay 

(slider) 

Description 

Set the time in seconds. Holds the beam if patient is out 

of tolerance for more than the selected time. When set in 

Preparation, it applies to all treatment sessions. When 

changed in Treatment, it applies only to the current 

beam of the current patient session. 

NOTE: Beam Hold Control is selected by default for every master template provided by Brainlab. 

It is recommended to keep this feature selected when designing templates, as well as for plan 

preparation. 

In case the automatic beam control is turned off, it is not the responsibility of ExacTrac Dynamic 

to stop the beam if the patient moved outside the defined patient thresholds. 

Breath-hold Settings 

Setting 

Imaging Window +/- 

Description 

Allowed tolerance for how much the breath-hold level 

can deviate from the planning CT level during imaging. 

The software displays a warning if the imaging level is 

outside of this window. 

Slider from 0.5 to 3 mm. 

NOTE: Only available for breath-hold treatments in surface-only 

modality. 

Reference Surface Window +/- 

Treatment Gating Window +/- 

Allowed tolerance for how much the breath-hold level 

can deviate from the imaging level when the reference 

surface is captured. 

The software displays a warning if there is a deviation 

from this tolerance. Deviations can influence the isocentric 

accuracy. 


Beam-on is allowed within this window with respect to 

the reference surface (today's treatment) level. 




Patient Position Tolerances 

Figure 18 

Patient Position Tolerances set in Preparation apply to all patient sessions. Changes made to 

the tolerances via ExacTrac Dynamic are applied to the current session. 

If Treatment is allowed to hold the beam and one of the dimensions exceeds its threshold, the 

software will interrupt the treatment until the patient is either back in tolerance or the user actively 

decides to disable the safeguards and continue treatment. 

For any setting, select the ⊕ or ⊖ symbols or move the slider with your mouse. 

The tolerance values (in mm) apply for all translational deviations: 

• Lateral 

• Longitudinal 

• Vertical 

• Distance 

NOTE: Distance is defined by the lateral, longitudinal and vertical values. 

The tolerance values (in °) apply for all rotational deviations (pitch, roll and couch angle). The 

following tolerances are calculated: 

• Pitch 

• Roll 

• Yaw 

Surface Camera 

Figure 19 


PREPARATION 

It may be necessary to adjust the Patient Skin Tone to achieve the best surface reconstruction 

possible. 

Use the slider to adjust to the best possible skin tone. Any changes made to the Patient Skin 

Tone, in either Preparation or Treatment, are stored for all patient sessions. 

Slider 

Patient Skin Tone 

Options 

• Light 

• Fair 

• Medium 

• Dark 


Preparation Workflows 

5.6 Preparation Workflows 

Patient Preparation Workflows 

The following pages provide examples for preparing a patient in Preparation using the available 

workflows. 

External Positioning with Surface Monitoring 

Step 

1. Start Preparation. 




NOTE: Only beams with couch angles up to ± 30° are allowed. 

4. Select a template from the list and select Confirm to proceed with the import. 

The plan settings are initialized by the template. 

5. Review and adjust plan settings as required. 

Under Workflow, select Surface Only. 

Under Positioning Device, select External (e.g. CBCT). 

6. Select Finish Patient Preparation. 

The software returns to plan selection. 

7. From the Menu, select Quit Preparation App to leave the application. 

Breath-hold External Positioning with Surface Monitoring 

Step 

1. Start Preparation. 



NOTE: Breath-hold workflows require two patient contours. 

NOTE: Only coplanar beams are allowed. 


4. Select a template from the list and select Confirm to proceed with the import. 

The plan settings are initialized by the template. 

5. Review and adjust plan settings as required. 

• Under Workflow, select Surface Only. 

• Under Positioning Device, select External (e.g. CBCT). 

• Toggle on Breathing Management and confirm that Breath-hold is selected. 

6. Continue to Contour Objects page and review the breath-hold reference contours. 

7. Select Finish Patient Preparation. 

The software returns to plan selection. 

8. From the Menu, select Quit Preparation App to leave the application. 


PREPARATION 

5.7 Isocenters Overview 

About Multiple and Virtual Isocenters 

ExacTrac Dynamic supports plans with multiple and virtual isocenters: 

• A multi isocenter plan uses several treatment beams with different isocenters. The setup fields 

have the same isocenter position as the associated treatment beam. 

• A virtual isocenter plan uses several treatment beams with the same isocenter. The isocenter 

of the setup beams differs from that of the treatment beams. When prepositioning with virtual 

isocenters, the maximum offset should not be greater than 10 - 15 cm in the dorsal direction. If 

the offset is higher, the patient may no longer be visible to the camera. 

In the case of a plan with multiple or virtual isocenters, you must prepare each isocenter (i.e., set 

the plan settings for each isocenter). The available isocenters are displayed on the Multi 

Isocenter Overview page. 

You cannot finalize plan preparation unless all isocenters contained in the plan have been 

prepared. If an isocenter is not prepared, any changes made will be deleted. 

Using Varian with Multiple Isocenters 

If you are using multiple isocenter plans with Varian integrations, no additional steps are required. 

ExacTrac Dynamic will automatically recognize all different isocenter positions of the treatment 

plan. 

Using Elekta with Multiple Isocenters 

Certain additional steps are necessary for planning, exporting and importing multiple and virtual 

isocenter plans with Elekta integrations to ensure that ExacTrac Dynamic can correctly recognize 

the different isocenter positions. 

To correctly import multiple or virtual isocenter plans into MOSAIQ, a site setup must be created 

for each isocenter. This step can be efficiently performed directly in your treatment planning 

system by using an associated prescription for each additional isocenter.MOSAIQ should now 

automatically create a site setup for each isocenter during import. 

Alternatively, you can manually create site setups in MOSAIQ. In this case, a site setup must be 

created for each isocenter. It is essential to enter the correct coordinates of the isocenter in the 

site setup. 


Isocenters Overview 

How to Prepare an Isocenter 

Step 

1. 

1 

2. 

On the Multi Isocenter Overview page, select an isocenter to prepare from the Isocenters 

menu 1. 

Select Prepare 1. 

1 


PREPARATION 

Step 

3. 

Review the information for the isocenter. 

• Adjust plan settings as necessary. 

• If you are satisfied, select Confirm. 

After review, a check mark appears next to the prepared isocenter in the Isocenters 

menu. 

1 

4. Repeat steps 1 - 3 until all isocenters are prepared. 

5. 

1 

When all isocenters are prepared, a green check mark is displayed next to Isocenters 1, 

indicating that all isocenters in the plan have been prepared. 

6. Select Finish Patient Preparation 2 to continue. 

2 


Finish Patient Preparation 

5.8 Finish Patient Preparation 

About Finishing Patient Preparation 

When all steps of the preparation workflow are complete, select Finish Patient Preparation. 

Plan Selection opens. You can: 

• Select and prepare a new patient. 

• Select Quit Preparation App from the Menu to leave the application. 


TREATMENT 

6 TREATMENT 

6.1 Overview of Available Workflows 

ExacTrac Dynamic Workflows 

The following pages describe typical surface-only treatment workflows for ExacTrac Dynamic as 

well as information regarding the usage of specific linacs. Which features are available for your 

system depends on your configuration, equipment and licenses. 

Brainlab recommends users follow the general provided workflows. Specific details within the 

workflows (e.g., default settings and thresholds) need to be specified by the user according to 

hospital or national guidelines. 

NOTE: Beam delivery automation is not supported by ExacTrac Dynamic. 


External Positioning Workflow 

6.1.1 External Positioning Workflow 

About External Positioning Treatments 

The following workflow allows you to position the patient using an external device, such as CBCT. 

External Positioning with Surface Monitoring 

Step 

1. Open patient plan on the linac. 

2. Perform prepositioning. 

Align the PTV to the linac isocenter. 

3. Select a surface tracking area that will be tracked by surface tracking throughout the external 

imaging procedure and treatment. 

4. Perform external positioning (e.g., CBCT) and confirm that the patient is in final treatment 

position. 

The reference for monitoring is set and patient tracking starts. 

5. Perform and monitor treatment. 

6. Perform repositioning if the patient moves out of tolerance. 

Related Links 

Loading and Confirming Plans on page 86 

Patient Prepositioning on page 92 

External Positioning with Surface Monitoring Workflows on page 96 

Surface Tracking Area on page 100 

External Imaging on page 123 

Patient Monitoring on page 125 


TREATMENT 

6.1.2 Breath-hold Workflow 

Requirements for Breath-hold Treatments 

To perform a breath-hold treatment, the following requirements must be fulfilled: 

• The system requires two reference contours from two different CT scans, which are used in 

irradiation planning and must be fused in the planning software (spinal fusion). 

- Free-Breathing Contour Plan: Derived from a CT acquired while the patient is breathing 

freely. 

- Breath-hold Planning CT: Derived from a CT acquired during a deep inspiration breath 

hold. 

• The system accepts treatment plans without couch rotations only. Plans with a couch rotation 

of more than 0° will be rejected. 

• To ensure that the reference contours can be assigned correctly for treatment, the naming 

convention has to be fulfilled. The names for the Free-Breathing Contour Plan and the 

Breath-hold Planning CT must be defined in the service settings following the naming 

convention of the treatment plan. 

• The contours of the Free-Breathing Contour Plan and Breath-hold Planning CT may only 

contain the external contour of the patient (i.e., the body shape). No internal structures and no 

artificial structures (e.g., table top) may be included in these contours. 

NOTE: The exception is a bolus that is part of the CT scan. 

• The Free-Breathing Contour Plan and Breath-hold Planning CT may not contain anything 

else but the patient's skin. 

NOTE: The exception is a bolus that is part of the CT scan. 

Using a Bolus 

If desired, you can use either a virtual or CT-scanned bolus with ExacTrac Dynamic. 

• A virtual bolus is added virtually (e.g., not physically) during planning and is not part of the CT 

scan. 

• A CT-scanned bolus is a physical bolus placed on the patient during CT scanning. 

How to Acquire a Free-Breathing CT 

To acquire the Free-Breathing CT, the patient should be relaxed with shallow, normal breathing. 

A slower scan technique is recommended to avoid that the scan is taken at inhalation/exhalation 

only. 

Step 

1. Position the patient. 

• Take as much time as necessary and encourage the patient to achieve a shallow, normal 

breathing pattern. 

• If patients are nervous and breathing fast and heavy compared to their normal breathing, 

give them time to relax and calm down. A Free-Breathing CT acquired with a 

heavily breathing patient will result in a reduced upstroke, which is unfavorable for a 

breath-hold treatment. 

2. Scan the patient. 

NOTE: The calculation of the upstroke between the Free-Breathing Contour Plan and Breathhold 

Contour is based on an average breathing level (baseline) that is calculated in free 

breathing. A Free-Breathing CT acquired at inhalation/exhalation only might result in an incorrect 

upstroke calculation. 


Breath-hold Workflow 

How to Acquire a Breath-hold CT 

For the Breath-hold CT, a fast scan protocol is recommended to make sure the scan can be 

completed within one breath hold. 

Step 

1. Position the patient in same position as for the Free-Breathing Contour. 

The patient should be relaxed with normal breathing. 

2. Guide the patient into a test breath hold and at the same time visually check that there is 

good upstroke. An upstroke of 10 to 20 mm on the patient sternum is recommended to 

achieve good results (depending on patient condition). 

Ensure that the breath hold is reached by normal inhalation only and not by a physical 

lifting of the chest. 

Allow the patient to breathe normally again. 

3. Guide the patient into a breath hold again and perform the scan while the patient is in the 

breath-hold state. 


Step 

1. Open patient plan on the linac. 

2. Perform prepositioning of the patient in free-breathing state. 

3. On the Respiratory Point page: 

• Select a respiratory point. 

• Calculate the baseline. 

4. On the Breath-hold Navigation page, acquire external imaging data: 

• Perform couch centering (Varian only), if required. 

• Guide the patient into a breath hold and the planned target. 

• Perform external imaging and mark external imaging events. 

• If external imaging events were marked, the reference surface is acquired automatically 

by ExacTrac Dynamic. Acquire the reference surface manually if the marking feature 

was not used. 

5. Verify the levels. 

• If the patient is within tolerance of the thresholds defined in Preparation, the workflow 

continues to step 6. 

• If they are not within tolerance, repeat steps 2 - 5, as required: 

- Modify external imaging level 

- Modify reference surface 

- Reacquire external imaging 

6. On the Surface Tracking Area page: 

Define an area of the patient's surface that will be tracked throughout the treatment. 

7. Perform and monitor treatment. 

Related Links 

Loading and Confirming Plans on page 86 

Patient Feedback System on page 89 

Patient Prepositioning on page 92 

Breath-hold Respiratory Point on page 104 

Breath-hold Navigation on page 106 


TREATMENT 

External Imaging on page 123 

Surface Tracking Area on page 100 

Patient Monitoring on page 125 


Loading and Confirming Plans 

6.2 Loading and Confirming Plans 

About Importing Plans 

All patient plans have to be imported (pushed) from the hospital's R&V system to the ExacTrac 

Dynamic system. 

If a plan has not been previously imported and the plan is opened at the linac while Treatment is 

running, the software informs you that the plan is not available for treatment with ExacTrac 

Dynamic but the treatment will still be authorized. 

If a plan has been imported previously and the plan is opened on the linac, how you proceed is 

determined by whether or not the plan has been prepared in Preparation: 

Options 

Not prepared 

Prepared 

Description 

• The plan opens in Preparation and you must go through the planning 

steps. 

• Exit the application. 

• The plan opens in Treatment. 

The plan opens in Treatment. 

About Loading Plans 

To load a plan, you must open a treatment plan on the linac. 

The plan loads in Treatment if it: 

• Was prepared with Preparation 

• Was exported to ExacTrac Dynamic 

• Should be treated using ExacTrac Dynamic 

NOTE: If the patient should not be treated using ExacTrac Dynamic (e.g., to a single day 

condition of the patient), you can select Reject and auto-authorize, which gives the authorization 

to proceed with treatment excluding ExacTrac Dynamic. 

If the plan has already been prepared, the Patient Confirmation page opens in ExacTrac 

Dynamic. You must review the patient data to ensure that the correct plan is loaded. The main 

treatment settings are also displayed for review. If the correct patient plan with the correct settings 

has been loaded, you can select Confirm Plan to proceed with patient setup. 

Notes on Loading Plans 

Warning 

Verify that the treatment plan loaded in the ExacTrac Dynamic system matches the 

treatment plan loaded on the linac, and ensure that the isocenter coordinates (ExacTrac 

Dynamic will always show the isocenter as DICOM coordinates) are correct by comparing 

them to the printout from the treatment planning system. This is especially important if the 

treatment plan has been updated in order to take possible problems (e.g., gantry/table 

collision, tumor shrinkage, boost planning) into account. 

Warning 

Verify that the correct patient data (e.g., patient name and ID, and plan date) is shown in the 

plan confirmation page. 

Warning 

Always verify that the patient on the couch is the patient opened for treatment on the linac 

and on ExacTrac Dynamic. 


TREATMENT 

Treatment Authorization for Varian Linacs 

The ExacTrac Dynamic system must always be running in order to authorize treatments on the 

linac using the ADI interface as all patient treatments must be authorized by the ExacTrac 


NOTE: Authorization is given for each individual beam, not per patient plan. 

Warning 

Once an authorization is given by the ExacTrac Dynamic system, it cannot be withdrawn 

via the ADI interface. Use automatic beam hold for patient monitoring during treatment 

instead. 

For details regarding ADI, as well as for general safety precautions, refer to the system 

documentation provided with your linear accelerator. 

Treatment Authorization for Elekta Linacs 

If the Elekta Service is running, the ExacTrac Dynamic system must also be running in order to 

remove the beam inhibit and start treatment. This also applies for treatment plans where the 

ExacTrac Dynamic system should not participate. 

• If the Elekta Service is not running, no beam inhibit is set and treatment is possible. 

• If the Elekta service is not running and a plan that had been exported to the ExacTrac 

Dynamic system is opened on the linac, treatment is also possible without ExacTrac Dynamic 

participating. 

Conditions for Beam Inhibit with Elekta Linacs 

A beam inhibit is set if any of the following occurs: 

• A plan is loaded and/or a beam is loaded 

• No patient has been positioned 

• There is a software or hardware error 

The beam is released when one of the following occurs: 

• The plan is rejected 

• The beam is approved 

• The system is powered down 

NOTE: As a result of this behavior, only load a patient plan after performing an iGUIDE daily 

check, if one is to be performed. 


Loading and Confirming Plans 

Plans with Multiple Isocenters 

Figure 20 

If your plan contains multiple isocenters, ExacTrac Dynamic loads the plan settings 

corresponding to the first beam treatment position. 

1 

Figure 21 

When a new beam with a different isocenter 1 is loaded on the linac, ExacTrac Dynamic saves 

the changes related to the old isocenter, and loads the plan settings corresponding to the linac 

treatment position. 


TREATMENT 

6.3 Patient Feedback System 

About the Patient Feedback System 

NOTE: The Patient Feedback System is applicable to breath-hold workflows only. 

The Patient Feedback System comprises both hardware and software and is intended for use 

during breath-hold workflows and supports the patient in reaching the correct breath-hold position. 

The system helps to visually guide the patient into a stable breath-hold position so that breathing 

can be maintained at an ideal breath-hold level throughout the treatment process. 

• Patient Feedback System: The mirror has a flexible arm and can be attached with a screw 

clamp to the head of the couch. The software is displayed on the ceiling-mounted monitor in 

the treatment room. 

• Patient Feedback Glasses: These can be used as an alternative to the mirror. 

For further information about the hardware, see the ExacTrac Dynamic System and Technical 

User Guide. 

Feedback Software on the Ceiling-Mounted Monitor 

4 

3 

5 

2 

1 

6 

Figure 22 

The patient feedback software on the Ceiling-Mounted Monitor helps patients visualize their own 

respiration and to achieve a correct breath hold, with or without the Patient Feedback System 

mirror or Patient Feedback Glasses. 

No. 

1 

2 

3 

4 

5 

6 

Description 

The gray circle represents the baseline position (average free-breathing position). 

The solid blue circle shows the live respiratory status of the patient. The circle moves up 

and down with each breath. 

The small unfilled orange circle shows the ideal respiratory status for breath hold. 

The large unfilled orange circle represents the breath-hold window in which the respiration 

(solid blue circle) must be before external imaging can be acquired (during the navigation 

step) or the treatment beam can be activated (during the monitoring step). 

The orange circle turns green as soon as patient respiration is within the breath-hold window. 

• If the Patient Feedback System is used with the mirror, select Flip Display to show a 

mirror image of the feedback software on the Ceiling-Mounted Monitor in the mirror. 

• If the Patient Feedback Glasses are used, no display flip is required. 

• The Patient Feedback System works with or without the mirror or glasses, as required. 


Patient Feedback System 

How to Clamp the Patient Feedback System to the Couch 

The Patient Feedback System mirror is clamped at the head-end of the couch, at the central 

axis. Attaching the system at any other point is not supported because it could result in a collision 

with the gantry or interfere with the X-ray imaging and linac beam. 

NOTE: Attaching the system to any device other than the couch (e.g., breast boards) can result in 

insufficient and instable fixation of the Patient Feedback System mirror. 

Step 

1. Ensure that both surfaces of the couch are clean and accessible. 

2. Open the screw clamp mechanism far enough that you can slide it onto the couch without 

damaging the surface. 

3. Adjust the clamp to the correct position on the central axis of the couch. 

4. Rotate the knob until both the upper and lower rubber pads touch the couch without being 

compressed. 

To avoid damaging the couch top or the device itself, a maximum rotation of two full turns 

is recommended from this point. 

NOTE: Do not use the clamp without the rubber pad. This could result in permanent damage 

to the couch. 

5. Check that the clamp is firmly in place. The clamp must not move while the mirror is being 

adjusted. 

NOTE: Tightening the clamp too firmly can damage the couch or the device itself. 

NOTE: Ensure that the device is correctly clamped to the couch before starting the treatment. 

NOTE: The device should not be used if the sleeve around the flexible arm shows any signs of 

deteriorating. 

How to Use the Patient Feedback System 

Step 

1. Position the Ceiling-Mounted Monitor near the foot of the patient couch, facing the patient. 

2. Attach the clamp of the Patient Feedback System mirror at the head of the patient 

couch. 

3. Without touching the reflective surface, position the mirror at an angle of approximately 

45°, until the patient can see the ceiling-mounted monitor clearly. 

4. Select Flip Display to show a mirror image of the feedback software on the Ceiling- 

Mounted Monitor. 

5. The patient (or clinic personnel) can now finely adjust the mirror without touching the reflective 

surface. 

6. Confirm with the patient that the monitor screen is fully visible in the mirror. 

NOTE: Prior to treatment, rotate the gantry and perform a visual inspection to detect possible 

collisions. 


TREATMENT 

How to Use the Patient Feedback Glasses 

Step 

1. Position the Ceiling-Mounted Monitor near the foot of the patient couch, facing the patient. 

2. Ask the patient to wear the prism glasses. 

It is possible to wear them on top of normal optical glasses, although the result is dependent 

on their frame shape and size. 

3. Check if the blue light reflections from the Patient Feedback Glasses are reflected back 

onto the camera. 

If yes, readjust the position of the glasses, preferably by moving the head of the patient 

horizontally. 

4. If needed, the clinical personnel can now adjust the height of the monitor, until the patient 

can see the ceiling-mounted monitor clearly. 

5. Confirm with the patient that the monitor screen is fully visible through the glasses. 

Reducing Surface Tracking Disruptions Caused by Blue Light 

At certain angles, surface tracking may be disrupted by the camera's blue light reflecting off of the 

Patient Feedback Glasses. In this case, the surface tracking on the monitor may go dark (either 

partially or completely) or result in an overall reduced surface quality. 

You can improve this situation by adjusting the patient's head position accordingly or by changing 

the position of the glasses to modify the angle of reflection of the blue light. 


Patient Prepositioning 

6.4 Patient Prepositioning 

Requirements for Prepositioning 

ExacTrac Dynamic uses the available surface tracking to determine a deviation shift. Send this 

shift to the couch to perform automatic prepositioning. 

• Always set up the patient correctly and be aware that rotational setup corrections using the 

treatment hardware are determined by the hardware used: The treatment hardware determines 

the limitations and the allowed setup tolerance on the treatment machine. 

• The linac gantry may either be in the top or bottom position while the couch rotation must be 

level before beginning patient positioning. 

• With automatic prepositioning, ExacTrac Dynamic corrects translations only. Correct rotational 

errors manually. 

NOTE: Depending on the selected workflow, prepositioning is possible at coplanar and noncoplanar 

beams. Breath-hold workflows allow coplanar beams only. 


TREATMENT 

6.4.2 Prepositioning 

About Prepositioning 

Align the patient to the linac isocenter using the live surface tracking and the planning CT 

Contour. 

Prepositioning with Elekta 

If you are prepositioning with Elekta to acquire an external position using Elekta, a setup beam 

has to be loaded on the linac. Setup beams cannot be recognized by ExacTrac Dynamic and 

therefore cannot be used for ExacTrac Dynamic prepositioning. 

Prepositioning Using a Virtual Isocenter 

Figure 23 

To use a virtual isocenter to preposition your patient, load the virtual isocenter beam on the linac 

and perform prepositioning as usual. 

ExacTrac Dynamic will not allow you to proceed with the workflow using this beam. In order to 

send the residual shift to achieve the treatment position, load the treatment beam and then 

continue with positioning the patient. 

Page Overview: Prepositioning 

2 

1 

3 

4 

Figure 24 


Prepositioning 


1 

View area 

A crosshair marks the isocenter. 

• White lines: Outer contour taken from the planning CT. 

- Breath-hold workflows: Outer contour taken from 

Free-Breathing CT. 

- External Positioning with Surface Monitoring: 

Outer contour taken from the planning CT or live reference 

surface from previous fractions. 

• Orange lines: Outer contour taken from the live surface. 

- If the live surface is red, move the patient closer to 

the isocenter or near the planned free-breathing position 

(for breath-hold workflows). 

- If the live surface is green, the patient is near the isocenter 

or near the planned free-breathing position 

(for breath-hold workflows). 

2 Shift values Displays values of the current shift. 

3 Send Shift Select to send the shift. 

4 Confirm Prepositioning Select to continue. 

How to Perform Prepositioning 

For all workflows, the following steps are required for patient prepositioning. 

Warning 

Always perform initial patient positioning at a couch angle of the first beam (treatment 

beam or setup beam). 

Step 

1. Open Treatment and carry out all required steps through Confirm Plan. 

2. Prepositioning opens. 

Use zoom to enlarge the image, if necessary. 

Use the live surface and contour of the patient as well as the values displayed to bring the 

patient close to isocenter position. 

If no values are displayed, this may result from: 

- A rotational offset of the patient above 15°. Ensure that the couch position is close 

to the planned couch position. 

- A missing detection of a matching surface. Ensure that the correct patient and plan 

are selected, that the treatment area is in the field of view of the 3D Camera, and 

that the treatment area is not covered by loose or bulky clothing. 

NOTE: If you select Send Shift, only translations are corrected. Rotational offsets must 

be corrected manually. 


TREATMENT 

Step 

3. 

Review values and contours before selecting Confirm Prepositioning. 

Warning 

Every single prepositioning fusion result must be inspected visually for correctness 

before sending the prepositioning shift. 


External Positioning with Surface Monitoring Workflows 

6.4.3 External Positioning with Surface Monitoring Workflows 

Prepositioning Prior to External Imaging 

• To use ExacTrac Dynamic prepositioning, load a treatment beam on the linac before acquiring 

the external position and perform prepositioning on the treatment beam. 

• It is recommended to perform prepositioning on a coplanar treatment beam to reduce 

movement of the couch between prepositioning and the external device positioning. 

• If external positioning has already been performed, do not send the ExacTrac Dynamic 

prepositioning shift (e.g., do not use ExacTrac Dynamic prepositioning to move the patient 

away from an externally-defined position). 

Page Overview: External Prepositioning 

2 

3 

1 

4 

5 

Figure 25 


1 

View area / live surface 

• A crosshair marks the isocenter. The outer contour taken 

from the planning CT or acquired live reference surface 

from the previous fraction. 

Live surface. 

• If the live surface is red, move the patient closer to the 

isocenter. 

• If the live surface is green, the patient is near the isocenter. 

2 Reference Surface Select a reference for prepositioning (see below). 

3 Shift values Displays values of the current shift. 

4 Send Shift Select to send the shift. 

5 Confirm Prepositioning Select to continue. 

For External Positioning with Surface Monitoring, the information about the prepositioning 

reference selection changes depending on which treatment session you are currently in. 


TREATMENT 

1 2 3 

Figure 26 

Description 

1 

2 

3 

In the first treatment session, prepositioning based on the outer contour is taken from the 

planning CT (if CT Contour is available). 

In the second treatment session, prepositioning can be based on: 

• The planning CT Contour (if available) 

• Live reference surface acquired from the first fraction 

In the third treatment session and onwards, prepositioning can be based on: 

• The planning CT Contour (if available) 

• Live reference surface acquired from the first fraction 

• Live reference surface acquired from the latest fraction 

NOTE: The First Reference Surface (first fraction) is permanently available, while the 

Latest Reference Surface will be overwritten in every session. 


Prepositioning in Breath-hold Workflows 

6.4.4 Prepositioning in Breath-hold Workflows 

Patient Prepositioning Quality 

In breath-hold workflows, the prepositioning quality has direct impact on the overall treatment 

accuracy. 

Always set up the patient correctly and be aware that rotational setup corrections using the 

treatment hardware is limited according to the hardware used. This relates to hardware limitations 

and the allowed setup tolerance on the treatment machine. 

If you confirm a prepositioning that exceeds tolerances or without a calculated shift, a pop-up is 

displayed. The pop-up reminds you that inaccurate prepositioning could result in inaccuracies 

during treatment. You can go back and preposition the patient again or continue with the workflow. 

NOTE: Imprecise prepositioning can result in inaccuracies during treatment. If the patient is 

prepositioned imprecisely, a warning is displayed and you must confirm that the positioning is 

intentional. 

Importance of Correct Patient Prepositioning 

4 

1 

2 

3 

5 

Figure 27 

Correct Patient Positioning 

• The expected position of the Breath-hold Contour on the Breath-hold Planning CT corresponds 

to line 1. 

• The Free-Breathing Contour on the Free-Breathing Contour Plan corresponds to line 2 

before treatment. 

• A respiratory point 3 is selected on the surface of the patient (e.g., on the sternum), that 

shows a steady and clear respiratory signal. 

• The respiratory signal is monitored at the respiratory point. A vertical axis 4 runs through the 

selected respiratory point. 

• The upstroke 5 is the difference in vertical amplitude between the Free-Breathing Contour 

and the Breath-hold Contour at a specific point (typically the respiratory point) on the patient 

surface. 


TREATMENT 

1 

3 

2 

4 

Figure 28 

Incorrect Patient Positioning 

• The upstroke 1 does not correspond with the respiratory point 2, meaning that the live respiratory 

signal shown in the software will be at the wrong anatomical position. 

• The expected upstroke 3 and the real upstroke 4 are not the same. The patient would then 

be guided into a wrong breath-hold target level, which could result in incorrect treatment. 

Using a Bolus with Breath-hold Workflows 

Bolus Type 

Requirements 

Warning 

The CT-scanned bolus must be part of the 

Breath-hold Contour and the Free-Breathing 

Contour (e.g., it is placed on the patient and 

CT scanned in free-breathing and breath-hold 

state). 

CT-scanned bolus 

Warning 

If the CT-scanned bolus is incorrectly positioned 

during prepositioning, it can negatively 

influence prepositioning shift. 

Warning 

Not placing the CT-scanned bolus in the freebreathing 

prepositioning can negatively influence 

the prepositioning shift, because the bolus 

is part of the Free-Breathing Contour (but 

not of the live surface). 

Virtual bolus 

Warning 

The virtual bolus must be placed when entering 

the Surface Tracking Area and/or Respiratory 

Point selection page. 

Warning 

The virtual bolus must not be placed in freebreathing 

prepositioning. 


Surface Tracking Area 

6.5 Surface Tracking Area 

About the Surface Tracking Area 

To track the patient's movement via surface tracking, select an area on the patient to be tracked 

by surface tracking. The surface tracking area should be selected in a way that it reflects 

movements of the PTV. 

NOTE: To track the patient's surface reliably, the surface tracking area should not be covered by 

loose or bulky clothing. 

Warning 

Significant changes in the patient's surface temperature might require new reference 

images for the surface tracking system. 

Surface Tracking Area Tools 

1 

2 

4 3 

Figure 29 

No. 

1 

2 

3 

4 

Description 

Currently defined surface tracking area 

Confirm Area 

Thermal map 

• Brush size: Change the size of the brush as required 

• Revert: Clears the currently defined tracking area 

Use the supplied tools (e.g., Brush Size) to indicate the tracking area. 


TREATMENT 

Figure 30 

You can paint arbitrary shaped areas on the patient. Those areas do not necessarily have to be 

connected to each other. However, all painted areas will be treated as exactly one rigid surface 

tracking area. 

With this information, the surface tracking algorithm estimates the motion of this tracking area, 

similar to the way a sensor in a shoe moves along exactly with the moving foot. 

To reliably track patient movement, ensure that no parts of the linac are included in the surface 

tracking area. For arc treatments, no gantry information can be included with the tracking area. If 

this happens, the rotation of the gantry may be considered as a tracked movement even if the 

patient does not move. As a result, the patient may be detected as out of tolerance and the beam 

may be held. 

ExacTrac Dynamic uses a smart tracking area concept. All parts outside of a predefined box 

centered at the isocenter of the patient plan will be considered irrelevant for tracking and 

excluded. Those parts are marked gray. 

When defining a surface tracking area, you may draw into a gray area, but it will not be 

considered for the final tracking area. Once you confirm the defined area, the gray parts will be 

removed from the tracking area. 

Surface Tracking Area Quality 

Although the thermal information provided by surface tracking improves the reliability of the 

tracking, it is nevertheless necessary to have enough 3D information in the tracking area to 

guarantee precise tracking results. 

When you select a tracking area, the system evaluates how well this area is suited for tracking. If 

the tracking quality is too low, Confirm Area remains grayed out, and you cannot proceed with 

the workflow. 

Always consider the overall "landscape" of the area you are interested in: A varied topography 

(e.g., facial hills and valleys) contributes more to improving surface tracking quality than a large, 

flat surface area can. 


Surface Tracking Area 

Troubleshooting Tracking Area 

Figure 31 

If you have trouble selecting a tracking area with a good quality, try to erase redundant (e.g., flat) 

parts from the area first. The selected surface tracking area shown here is too flat and too 

symmetrical to be effective. 

Tracking Area on Subsequent Beams 

Once you have defined a tracking area, it is usually not necessary to redefine it for subsequent 

beams. 

However, if not enough points of the tracking area are visible after transferral and the calculated 

quality is too low, the system will force you to adjust the tracking area for the new couch angle to 

continue. 

Notes 

Warning 

Heated or heating blankets are not suitable for use with ExacTrac Dynamic because these 

can lead to incorrect temperature shifts during positioning and monitoring. 

Warning 

If the tracking area is placed on the iGUIDE reference frame, the monitoring based on 

surface tracking tracks couch movements only, which might not correspond to the patient 

movement. 

Warning 

In cases where closed face masks are used as a patient fixation device, only the mask itself 

is tracked by the surface tracking and not the patient's surface. 


TREATMENT 

How to Define the Surface Tracking Area 

Step 

1. 

The Surface Tracking Area page opens. 

2. Define a tracking area appropriate for your procedure. 

3. Use the brush to mark the boundaries of the tracking area. 

Adjust the brush size with the slider. 

Reset the brush and/or tracking area, if necessary. 

NOTE: You can use the right mouse button to erase the selected area. 

4. Once the tracking area is satisfactory, select Confirm Area. 

If the patient was already treated, the tracking area is preselected and will be displayed. 

Select Confirm Area if the area displayed is correct, or use the tools to adjust the area. 

Confirm that the tracking area is still at the expected position because the tracking area is 

defined according to the camera field of view, not patient or linac coordinates. As an example, 

the treatment machine has changed since the previous fraction, and as a result 

the tracking area is shown at a slightly different position. 

How to Define the Surface Tracking Area for Breath-hold Workflows 

The surface tracking area is defined after Breath-hold Navigation, after positioning. 

The surface tracking area is defined on the static reference surface in top view, acquired in the 

breath-hold state. 

NOTE: In breath-hold workflows, an appropriate surface tracking area includes an area located on 

a structure, which moves with the breathing motion. 


Breath-hold Respiratory Point 

6.6 Breath-hold Respiratory Point 

About the Respiratory Point 

To accurately track the patient's breathing during navigation and treatment in breath-hold 

workflows, use the Breath-hold Respiratory Point page to: 

• Set a respiratory point 

• Calculate the baseline 

To generate the patient's respiratory signal for tracking, define a respiratory point. The respiratory 

point is a position on the surface of the patient (e.g., the sternum), that shows a steady and clear 

respiratory signal. The respiratory signal is the vertical motion of this surface point due to 

respiration. 

Page Overview: Breath-hold Respiratory Point 

1 

4 

Figure 32 

3 

2 


1 View area Shows the patient's surface. 

2 

3 

4 

Confirm Baseline 

Respiratory Signal and Levels 

Set Respiratory Point and 

Calculate Baseline 

Select when respiratory point and baseline are acceptable. 

Shows the respiratory signal and the levels in parallel 

graphs (in mm). After successfully calculating the baseline, 

the respiratory gating window for the breath hold is 

also shown here. 

• Select to set a respiratory point, or change the position 

of the currently saved point. 

• Select to calculate a baseline, or delete the currently 

saved baseline and calculate a new one. 


TREATMENT 

Respiratory Point 

• The respiratory point should be positioned on an even surface with no significant gradient 

changes surrounding it. 

• Select a respiratory point on an area of the patient's surface where the breathing of the patient 

provides a large and stable upstroke with low signal noise. The upstroke should be significantly 

larger than the breath-hold window size. 

• A good respiratory point is typically around the patient's sternum. 

Baseline 

The baseline (the average respiratory signal of the patient breathing freely) is calculated from the 

respiratory signal at the respiratory point. 

After the baseline is generated, the upstroke at the respiratory point is calculated, being the 

vertical distance between the contours on the Free-Breathing Contour Plan and the Breathhold 

Planning CT at the respiratory point on the patient surface. 

How to Select a Respiratory Point and Calculate a Baseline 

Step 

1. Use the respiratory point tools to define a respiratory point on the patient surface. 

2. Evaluate the drawn respiratory curve and ensure that it shows a steady and clear respiratory 

signal. 

3. Calculate a baseline while the patient is breathing freely and inspect the calculated upstroke 

for plausibility (e.g., around 20 mm). 

4. Select Confirm Baseline to continue. 

Using a Bolus 

Warning 

For both CT-scanned bolus and virtual bolus: 

• Place the respiratory point in a way that it either always or never intersects the bolus on 

the live surface. 

• Do not place the respiratory point close to a border of the bolus. 

• When switching from a non-bolus field to a bolus field or vice versa, it is strictly 

recommended to restart from free-breathing prepositioning because the acquired 

references will be influenced by physically adding or removing the bolus. 


Breath-hold Navigation 

6.7 Breath-hold Navigation 

6.7.1 Breath-hold External Positioning with Surface Monitoring 

About Breath-hold Navigation with External Positioning 

In the navigation workflow step, you guide the patient into one or more consistent and stable 

breath-holds and acquire the external imaging data. The external imaging data can be a conebeam 

CT (CBCT) or any 2D image modality. The data is then used to position the patient for 

treatment. 

Generally, there are three main steps in Breath-hold Navigation: 

• Getting the patient to perform a breath hold as close to the planned level as possible. 

• Performing external imaging, which also includes marking imaging events on ExacTrac 

Dynamic and monitoring patient movement. 

• Confirming imaging is complete and then positioning the patient. 

The following section will explain the steps in more detail. 

Planned Level 

The Planned Level is the breath-hold level goal for the patient during treatment, as established in 

the plan. 

The Planned Level is calculated from the vertical difference (upstroke) between the Free- 

Breathing Contour and the Breath-hold Contour at the respiratory point. 

Imaging Window 

Figure 33 

When the navigation step first opens, the respiratory graph shows only the Baseline, Planned 

Level and the imaging window. As you progress through the workflow, other levels become 

available. 

The imaging window is a guidance tool for the user and the patient to achieve a stable breath hold 

close to the Planned Level. The size of the imaging window can be defined in Preparation. It is 

independent of the treatment gating window, which defines the breath-hold tolerance for 

treatment. 


TREATMENT 

Only perform imaging when the patient's respiratory signal is within the imaging window and is as 

close as possible to the Planned Level. 

Figure 34 

If used with the Patient Feedback System, the imaging window corresponds to the outer circle 

(e.g., green circle) in the patient feedback software. 

Imaging Level 

NOTE: Imaging Level applies to Breath-hold External Positioning with Surface Monitoring 

only. 

Figure 35 

The Imaging Level is the average respiratory level during CBCT or 2D imaging acquisition. To 

achieve a precise treatment, ensure that imaging events are marked correctly in ExacTrac 

Dynamic. A correct Imaging Level can now be calculated. 

• For CBCT, marking external imaging events ensures that ExacTrac Dynamic continuously 

records and calculates an average respiratory level. 

• For 2D imaging, marking the 2D imaging time ensures that ExacTrac Dynamic records and 

calculates an average respiratory level. 



Treatment Level (Reference) 

While performing treatment, the live surface of the patient is matched with a Reference Surface. 

Because the external imaging shift is used to position the patient in the navigation step, the 

surface reference should also match the patient surface during external imaging. 

There are two ways to create the Reference Surface: 

• Automatically generate one via ExacTrac Dynamic and the provided marking functionality. 

This ensures a more precise treatment, because both the Imaging Level and Reference 

Surface will be calculated correctly. 

• Manually generate one in a second step. This option requires asking the patient to perform 

another breath hold to acquire a Reference Surface. See the related links for further 

information. 

NOTE: A Reference Surface that deviates from the average surface during external imaging 

would result in treatment errors. 

NOTE: The Treatment Level (Reference) is the respiratory level at which the Reference Surface 

was acquired. 

Related Links 

How to Manually Define Imaging Level on page 120 

How to Manually Acquire the Reference Surface on page 121 

Target Adjusted 

If the patient cannot reach a breath-hold level at the level displayed in the imaging window or the 

achieved breath-hold level deviates significantly from the Planned Level, you may decide to 

adjust the planned level. For example, if the patient: 

• Is unable to reach the planned breath-hold level (e.g., because the patient is in poor condition 

on the day of treatment). 

• Exceeds the planned breath-hold target level, which could be the case if the Breath-hold CT 

scan was not performed at a correct breath hold. 

If you have sufficient user rights, you can adjust the level using the option Enable breath-hold 

target level adjustment. 

The adjusted level is called Target Adjusted and should match the patient breath-hold level of the 

day. 

NOTE: With a shallower breath hold, organs at risk such as the heart could be closer to the 

treatment beam and therefore receive a higher dose of radiation than calculated by the treatment 

plan. 

How to Adjust Breath-hold Level 

You can only adjust breath-hold level if you have sufficient user rights. 

Adjustment alters the planned treatment, resulting in a deviation from the treatment plan. It 

requires in-depth clinical knowledge and treatment-plan specifics of the patient. 


TREATMENT 

Step 

1. 

Open the menu and select Breath-hold. 

2. Select Enable breath-hold target level adjustment. 

3. 

A pop-up informs you why adjusting the levels could potentially cause harm to the patient. 

4. Select OK. 

5. 

1 

2 

• Adjust the Planned Level 3 using the Adjust Target + and - buttons 1. 

• Once an adjustment is done, a new level called Target Adjusted 2 appears in the 

graph. The adjustment should be done in a way that the Target Adjusted level matches 

today's breath-hold level of the patient. 

• The Target Adjusted is only valid for the current fraction and will be reset for the next 

fraction. 

NOTE: The imaging window is connected to the Target Adjusted level and will move with the 

level as this is adjusted. The imaging window does not remain at the initial Planned Level. 

3 

NOTE: An adjusted target level will result in a different lung inflation state compared to treatment 

planning. This means OARs (especially the heart) may be at a different position than the planned 

position. 



How to Perform Couch Centering with Varian 

If you are using CBCT scans and a Varian TrueBeam system, it is sometimes necessary to move 

the couch to a centered position that is different from the isocenter position. 

Step 

1. 

Before entering the navigation page, a pop-up is displayed. 

• Select Perform Couch Centering to start the couch centering process. 

• Select Skip Couch Centering to proceed directly to navigation. 

2. 

If Perform Couch Centering was selected, move the couch to the centered position. 

3. Select Confirm & Continue to proceed to Navigation. 


TREATMENT 

Step 

4. 

1 

3 

2 

• If couch movement is detected, the dialog closes and the workflow continues to Navigation. 

• If no couch movement is detected 1 the software asks you to ensure that the couch is 

in the intended position. 

- If you want to continue to Navigation without moving the couch, select Continue 

with Zero Shift 3. 

- To correct the position, move the couch to the centered position and select Update 

Shift & Continue 2. 

Page Overview: Surface Breath-hold Navigation 

2 

3 

1 

7 

6 

5 

4 

Figure 36 




1 

2 

3 

Respiratory Signal and 

Levels pane 

Legend 

External Imaging Done 

Displays live patient respiratory signal over time and 

imaging window. 

Dynamic Zoom toggle: Zooms in automatically when the 

breath hold is within the imaging window. 

Shows the difference between the actual surface and the 

target surface using gradients. 

NOTE: On the Breath-hold Navigation page, the target 

surface is now the Breath-hold Contour, not the Free- 

Breathing Contour, as seen on the Free-Breathing 

Prepositioning page. 

Becomes active when the patient is in a free-breathing 

state and at least one breath hold was performed. 

4 Workflow guidance Displays information about next steps or tasks. 

5 Live Respiration pane Live respiratory signal of the patient. 

6 CBCT or 2D Imaging Select an imaging modality. 

7 

Mark CBCT Start or Mark 

2D Image 

Begin marking defined imaging events. 

Treatment Level (Reference Surface) with CBCT 

If the CBCT imaging events are marked, ExacTrac Dynamic will continuously calculate an 

average respiratory level for the times when the CBCT was in acquisition mode (as defined by the 

controls Mark CBCT Start and Mark CBCT Stop). 

ExacTrac Dynamic automatically acquires a Reference Surface. If an incoming surface is closer 

to the average level than the existing reference surface, this new surface becomes the new 

Reference Surface. 

After external imaging is completed, the calculated average respiratory level becomes the 

Imaging Level and the latest Reference Surface defines the Treatment Level (Reference). 

Treatment Level (Reference Surface) with 2D Imaging 

For 2D imaging, ExacTrac Dynamic will record the surface at the first defined imaging event 

(Mark 2D Image) and store it as a Reference Surface. 

The Imaging Level is calculated as the average respiratory level of all imaging events. 

Therefore, if you are acquiring multiple 2D images, it is important to acquire all 2D images ideally 

at the Planned Level, or at least at an identical respiratory level for all 2D images. Otherwise the 

Treatment Level Reference and the Imaging Level will deviate and it may be necessary to 

manually acquire a new Reference Surface at the Imaging Level. 


TREATMENT 

How to Acquire a CBCT and Record the Acquisition Time in ExacTrac Dynamic 

Figure 37 

Depending on your system, you may wish to acquire CBCT images. 

Step 

1. Prepare your CBCT imaging device. 

Set it up so that you can begin acquisition as soon as the patient is in a stable breath 

hold. 

2. Ensure that CBCT Imaging is selected. 

3. Guide the patient into a stable breath hold, so that the respiratory signal is inside the 

imaging window and as close as possible to the Planned Level. 

NOTE: ExacTrac Dynamic will indicate a breath hold has been detected by zooming in in 

the imaging window. However, it cannot detect the quality or stability of the breath hold. 

4. Simultaneously: 

• Start CBCT acquisition on your imaging device. 

• Start the marking of an imaging event in ExacTrac Dynamic by selecting Mark CBCT 

Start. 

5. The CBCT acquisition is now indicated in the respiratory graph (shaded pink). Monitor the 

patient respiratory signal. 

6. After a sufficient time span (e.g., the time that the patient can typically maintain a stable 

breath hold), simultaneously: 

• Select Mark CBCT Stop in ExacTrac Dynamic. 

• Stop CBCT acquisition on your imaging device. 

7. Tell the patient to breathe freely again. 

8. If you are done with acquisition, select External Imaging Done. 

NOTE: Only apply external imaging correction shift after confirming External Imaging 

Done. 



Step 

9. When confirming External Imaging Done, ExacTrac Dynamic checks for the defined 

settings (e.g., imaging window, treatment reference window). 

• If you are within the set tolerances, you are directed to the shift retrieval dialog. 

• If you are not within the set tolerances, you must verify the respiratory levels. 

How to Acquire 2D Images and Record the Acquisition Time in ExacTrac Dynamic 

Figure 38 

Depending on your system, you may wish to acquire 2D images and move the couch between 

images to improve accuracy. 

Step 

1. Prepare your 2D imaging device. 

Set it up so that you can begin acquisition as soon as the patient is in a stable breath 

hold. 

2. Ensure that 2D Imaging is selected. 

3. Guide the patient into a stable breath hold, so that the respiratory signal is inside the 

imaging window and as close as possible to the Planned Level. 

NOTE: ExacTrac Dynamic will indicate a breath hold has been detected by zooming in in 

the imaging window. However, it cannot detect the quality or stability of the breath hold. 

4. Simultaneously: 

• Acquire a 2D image acquisition on your imaging device. 

• Acquire an imaging event in ExacTrac Dynamic by selecting Mark 2D Image. 

5. Tell the patient to breathe freely again. 

6. If you want to acquire another 2D image with a couch move in between the two acquisitions: 

• Select Intermediate Shift and move the couch as soon as the shift dialog appears. After 

the couch move, you can then repeat steps 3 - 5. 


TREATMENT 

Step 

7. If you are done with your acquisition, select External Imaging Done. 

NOTE: Only apply external imaging correction shift after confirming External Imaging 

Done. 

8. When confirming External Imaging Done, ExacTrac Dynamic checks for the defined 

settings (e.g., imaging window, treatment reference window). 

• If you are within the set tolerances, you are directed to the shift retrieval dialog. 

• If you are not within the set tolerances, you must verify the respiratory levels. 

How to Retrieve a Shift for Varian Linacs 

Figure 39 

NOTE: Apply external imaging correction shift only when the shift retrieval pop-up is displayed. 

Step 

1. If you are using a Varian linac system, ExacTrac Dynamic will automatically retrieve 

couch positions before and after patient positioning and calculate the applied shift. 

2. An automatic check detects whether couch movement has occurred. 

If couch movement is detected, the dialog closes and the workflow continues to the Surface 

Tracking Area page. 

If no couch movement is detected, the software asks you to ensure that the couch is in 

the intended position. 

• To continue to the Surface Tracking Area page without moving the couch, select 

Continue with Zero Shift. 

• To correct the position, move the couch to the final treatment position and select Update 

Shift & Continue. 

NOTE: You can always go back to Navigation to verify levels and treatment accuracy by 

selecting Show Respiratory Levels. 



How to Retrieve a Shift for Elekta Linacs 

Figure 40 

If you are using an Elekta linac system, the applied couch shift for the base table can be retrieved 

the same way as shown in the Varian case above. However, the shift needs to be entered 

manually in ExacTrac Dynamic for the HexaPOD couch. A dialog box allows the user to select 

which table to use. 

Step 

1. If you are using a HexaPOD system and you have a large shift that cannot be applied by 

the HexaPOD alone, make sure you enter the entire shift before it is split between the 

base table and HexaPOD. Be careful to enter the shift correctly. 

2. An automatic check detects whether couch movement has occurred. 

If couch movement is detected, the dialog closes and the workflow continues to the Surface 

Tracking Area page. 

If no couch movement is detected, the software asks you to ensure that the couch is in 

the intended position. 

• To continue to the Surface Tracking Area page without moving the couch, select 

Continue with Zero Shift. 

• To correct the position, move the couch to the final treatment position and select Update 

Shift & Continue. 

NOTE: You can always go back to Navigation to verify levels and treatment accuracy by 

selecting Show Respiratory Levels. 


TREATMENT 

How to Enter the Shift 

1 

3 

Figure 41 

2 

Step 

1. Enter the shift values in the fields provided 1. 

2. Select OK 2. 

3. 

NOTE: You can always go back to Navigation by selecting Show Respiratory Levels 

3. 

1 

2 

Review the values again and edit them if they are incorrect 1. 

If the shift is acceptable and the values are correct, select Confirm & Continue 2. 



How to Verify Levels and Treatment Accuracy 

1 

2 

3 

4 

Figure 42 

If you want to review the treatment accuracy (e.g., you selected Show Respiratory Levels before 

entering a shift), you can evaluate the correctness of the Imaging Level and a Reference 

Surface by following these steps. 

NOTE: In most cases, if the patient is within tolerance of the thresholds defined in Preparation, 

you will not need to perform this step. 

Step 

1. Check the position of the Reference Surface acquisition time within the respiratory 

graph. Verify that: 

• The Reference Surface was acquired at a stable respiratory level (e.g., not during 

coughing or quick inhalation/exhalation). 

• The Reference Surface was acquired as close as possible to the Imaging Level. 

2. Verify that the levels are within the thresholds defined in Preparation. Compare: 

• Planned Level and Imaging Level (e.g., the imaging window size). 

• Treatment Level (Reference) and Imaging Level. 

3. If the Reference Surface and levels are acceptable and within tolerance, select Confirm 

4. 

4. If any of the thresholds set in Preparation are exceeded, a warning is displayed. Available 

options: 

• Select Discard & Repeat External Imaging 1. You can go back to the navigation 

page and repeat the external imaging procedure. 

• Select Edit Imaging Level 2. You can adjust the imaging level based on the breathhold 

signals. 

• Select Re-Acquire Reference 3. You can re-acquire the reference surface manually. 

• Select Accept & Continue. Enter your credentials to accept the deviation. 

NOTE: To accept the deviation, you must have sufficient user rights. 

Adjustment alters the planned treatment, resulting in a deviation from the treatment plan. 

It requires in-depth clinical knowledge and specific information from the patient's treatment 

plan. 


TREATMENT 

Example: Verifying Levels 

Figure 43 

Good example: 

• The Reference Surface was acquired at a stable respiratory level and as close as possible to 

the Imaging Level. 

• The levels between Planned Level and Imaging Level and the levels between Treatment 

Level (Reference) and Imaging Level are within the thresholds defined in Preparation. 

Ideally, all three are at the identical respiratory levels with zero or minimal deviations. 

1 

Figure 44 

2 

Bad example: 

• Warnings are displayed that some levels exceed thresholds defined in Preparation 1. In this 

example, there is a deviation between breath-hold levels and reduced isocenter accuracy. 

• Additional information is displayed under the imaging window about how the displayed levels 

will affect treatment 2. 



How to Manually Define Imaging Level 

Figure 45 

If an Imaging Level was not calculated automatically, you must define it manually. 

This may be necessary if you selected Imaging finished after completing external imaging but 

without marking any imaging events. 

Step 

1. Examine the frozen respiratory graph and remember where the external imaging was performed 

in the shown breath holds. 

2. Estimate the average respiratory level across the external imaging times. 

3. 

Set the Imaging Level to the average respiratory level that you estimated via the mouse 

wheel and/or the positioning arrows. 

NOTE: If the manually defined imaging level does not correspond to the level where 

imaging was performed on the linac, the treatment plan will be inaccurate. This changes 

the planned treatment, resulting in a deviation from the treatment plan. It requires in-depth 

clinical knowledge and specific information from the patient's treatment plan. 

4. Confirm the correctness of the manually defined Imaging Level. 

NOTE: It is important to monitor the patient position between finishing the external imaging 

and the manual acquisition of a Reference Surface. Any undetected patient motion 

during this time will result in an inaccuracy during patient treatment. 


TREATMENT 

How to Manually Acquire the Reference Surface 

Figure 46 

When no Reference Surface is available, you must acquire a new one manually. Reasons for a 

missing reference surface include: 

• No imaging events were marked 

• The calculated Imaging Level was adjusted 

• An existing Reference Surface was deleted 

Step 

1. Guide the patient into a breath hold. The target is the Imaging Level. 

Use the reference surface window as a tolerance around the target for the acquisition of 

the reference surface. 

2. When the patient respiratory level matches the Imaging Level, select Acquire. 

A new reference surface is acquired. 

3. Verify that the levels and treatment accuracy. 

Deviations Between Different Levels 

Deviation Between Cause Result 

Planned Level and Imaging 

Level 

External imaging was not performed 

at the identical respiratory 

level as the Breath-hold 

CT. 

The treatment will be performed 

with a different amount 

of inhalation (lung filling) when 

compared to the treatment 

plan. 

The target and/or OARs may 

be at different locations compared 

to treatment planning. 



Deviation Between Cause Result 


and Imaging Level 

The Reference Surface was 

not acquired at the Imaging 

Level. Potentially, the Reference 

Surface deviates from 

the average patient surface 

during imaging. 

The patient is positioned 

based on the external imaging, 

but is treated based on the 


A treatment inaccuracy the 

size of the deviation between 

the two levels may occur. 

Intended and Unintended Couch Shifts 

Intended couch shifts coming from third-party linac can only be applied once you have confirmed: 

• The correctness of the various respiratory levels and the Reference Surface in the final 

navigation screen. 

(If the patient is within tolerance of the thresholds defined in Preparation, you will not need to 

perform this step.) 

• The correctly retrieved/entered couch shift 

Any couch shift outside this defined time slot will bring the workflow automatically back to the 

prepositioning step. All generated data will be lost. 


TREATMENT 

6.8 External Imaging 

About External Imaging 

You can choose an external imaging device (e.g., CBCT) to define the planned treatment position 

of the patient. 

For all workflows where external imaging is selected as a positioning modality, the patient can be 

tracked while performing the imaging. 

Page Overview: External Positioning 

1 2 3 

Figure 47 

5 

4 


1 Surface pane Live surface of the tracked patient. 

2 

Movement pane 

Shows surface movement of the patient during external 

imaging. 

3 Workflow guidance Displays steps to be performed. 

4 

5 

Positioning Finished 

Reset Tracking 

For surface monitoring, the reference surface is updated 

and used for patient monitoring during treatment. 

Deletes deviations shown on the surface view, resets deviations 

to zero and sets a new tracking reference. 

This page displays possible patient movement represented in the surface views and distance 

bars. 

Patient tracking is triggered once entering the page. Hence, shown patient movements may result 

before, during or after external imaging. 

NOTE: ExacTrac Dynamic will not hold the beam if the patient is out of tolerance (e.g., there is 

no gated external imaging possibility). 


External Imaging 

How to Use Reset Tracking 

If you are using external imaging and you have not yet started the imaging acquisition, you can 

select Reset Tracking to set a new tracking reference. This is helpful if the patient moves before 

starting the acquisition or when performing couch centering (only applicable for Varian users). 

Step 

1. Acquire images (e.g., CBCT). 

2. If the patient moves during the acquisition procedure and you want to restart your image 

acquisition, select Reset Tracking to delete any displayed movement. 

• Deviations are reset to zero (+/- breathing motion, depending on selected surface 

tracking area). Any new patient movement can be accurately assessed. 

• You can select Reset Tracking at any time to set a new reference and delete displayed 

movement. 


TREATMENT 

6.9 Patient Monitoring 

About Patient Monitoring 

NOTE: This chapter will provide general information about patient monitoring applicable to most 

workflows. It is recommended to read this information first, then read the additional information 

related to breath-hold or surface-only workflows found in the subsequent subchapters and related 

links. 

During the monitoring phase, ExacTrac Dynamic provides information from the 3D Camera and 

Thermal Camera and visualizes patient movement as detected during surface tracking on the 

Patient Monitoring page. 

Depending on your workflow, you can use the information displayed on the Patient Monitoring 

page to verify that the patient has not moved out of tolerance during treatment. 

Tolerances and Beam Hold Settings 

• Tolerance and/or beam hold settings were set in Preparation. 

• The tolerance and/or beam hold settings established in Preparation determine the range of 

tolerance for patient movement during treatment. 

• If required, you can change the tolerance values via the menu during patient monitoring. These 

changes apply only to the current session. 

Visual Status Information 

• Information from surface tracking system is displayed in the view pane on the workflow's 

Patient Monitoring page. The Patient Position pane provides visual status information about 

surface tracking, tolerance status and beam status. 

• For breath-hold workflows, information is displayed in the view panes on the workflow's Patient 

Monitoring page. The Breath-hold Gating Status pane provides visual status information 

about surface tracking, the respiratory signal and the beam status. 

Notes 

Warning 

If you need to enter the treatment room while the beam hold interlock is set, turn off the 

MV. 

Warning 

Use only an image fusion with a defined, restricted region/volume during monitoring that 

resulted in an accurate image fusion during positioning. 

Warning 

While using surface tracking to monitor patient movements, be aware that the camera 

needs a clear and unblocked view on the patient during the entire treatment. 

Warning 

Keep a constant temperature in the treatment room, to avoid that the patient's surface 

cools down. 

Related Links 

Breath-hold Settings on page 73 

Status Information on page 163 


Patient Monitoring 

Notes Applying to External Positioning Workflows 

After performing positioning with an external device, you can use ExacTrac Dynamic for 

monitoring. 

If the patient moved during treatment, and repositioning is performed by ExacTrac Dynamic, 

ExacTrac Dynamic will always position the patient at the defined external reference position. 

Warning 

Be aware that ExacTrac Dynamic monitoring is limited to detecting movements via surface 

tracking, which is not reliable for detecting soft tissue. After external positioning 

acquisition, any soft tissue target movement that occurs relative to the bony structure and 

the patient's surface cannot be detected reliably. 

Beam Authorization Prerequisites 

To be able to start the MV beam on the linac, the beam needs to be authorized by ExacTrac 

Dynamic. Authorization is only given if: 

• The couch is at the planned treatment position. 

• The 3D Camera with thermal overlay displays the patient in the correct treatment position. 

(This does not apply if a beam hold by ExacTrac Dynamic in which the patient was out of 

tolerance has been ignored.) 

Always select the current field/beam to inform ExacTrac Dynamic about the expected treatment 

position. ExacTrac Dynamic can only continue treatment if the beam is prepared. 

Page Overview: Surface-Based Patient Monitoring 

1 

2 

5 

Figure 48 

4 

3 


1 Surface pane Visual of patient with surface tracking and legend. 

2 

Movement pane 

Values show how closely patient remains within or out of 

tolerance (in mm). 

3 Patient Position pane Visual monitoring status of patient position. 


TREATMENT 


4 

Dynamic (All): 

Select to view: 

• Distance 

• Lateral 


• Vertical 

Dynamic (All): Shows the dimension that is currently 

most critical in relation to its own tolerance. 

Distance: Shows the length of the vector of all translation 

offsets. 

5 Patient Movement pane Live respiratory signal of the patient. 

Legends 

1 2 3 

Figure 49 

Images from both the 3D Camera and the Thermal Camera are accompanied by legends to help 

users determine if the patient is properly positioned. 


1 

2 

3 

3D Camera 

Tracking Area 

Thermal Camera 

Uses a green-to-red legend. 

This view shows the distance of the surface points of the 

current position compared to the moment tracking was 

started. 

The default values are: 

• Green is 1 mm or less 

• Red is 10 mm or more 

Represents the tracking area selected by the user. 

Appears as a white overlay with white contour. 

3D Camera: To be in tolerance, the tracking area should 

be visible in the green range. 

Uses a yellow-to-purple legend. 

• Yellow is Warm 

• Purple is Cold 



Page Overview: Breath-hold Patient Monitoring Without X-rays 

1 

2 

3 

5 

6 

4 

Figure 50 


1 

Beam, couch angle and gantry 

information 

If Door Open is displayed, one of three things are possible: 

• The treatment room door is open. 

• XVI is active. 

• The patient table brakes are not locked. 

2 Surface monitoring pane Visual of patient with surface tracking and legend. 

3 

4 

Breath-hold Gating Status 

pane 

Respiratory Signal and Levels 

pane 

Visual monitoring status of patient position, respiratory 

state and treatment beam state. 

Patient's live respiratory signal with Baseline, Treatment 

Level (Reference) and breath hold shown. 

Out of Tolerance Options 

If the patient is out of tolerance, you have the following options from the Patient Monitoring page: 

Option 

Select External Repositioning 

Select Ignore (prerequisite: At 

least 1 MU was previously 

radiated) 

Result 

Go back to prepositioning and reposition using an external 

imaging device. 

Continue treatment, but without using ExacTrac Dynamic. 


TREATMENT 

Next Beam with Different Couch Angle 

Figure 51 

NOTE: Next beam is not applicable for breath-hold workflows. 

If the planned couch angle differs from the previous beam, a couch rotation dialog is shown on the 

Monitoring page when switching to the next beam. 

The dialog closes automatically when the couch rotation reaches the planned value. 

NOTE: Ensure that the beam is selected on the linac before rotating the couch to the new target 

angle. 

The area tracked by surface tracking might get lost in case of unknown large rotational 

movements that are not indicated to ExacTrac Dynamic by beam selection. 

Using Automatic Beam Hold 

Figure 52 

During treatment, when automatic beam hold is on, the software automatically holds the beam 

when patient movement exceeds the tolerance values set in Preparation. 

When automatic beam hold is off, the software does not hold the beam during treatment when 

patient movement exceeds the tolerance values set in Preparation, but it does warn the user that 

the patient is out of tolerance. The user must manually stop the beam from the linac console. 

Even when automatic beam hold is on, the user can stop the beam at any time via the linac 

console. 

Use the Menu to return to the settings during treatment to change tolerances, if required, or toggle 

automatic beam hold on or off. 



NOTE: For breath-hold workflows, this setting cannot be turned off. 

NOTE: Automatic beam cut off may not be used for respiratory gating. 

NOTE: Use the Surface out of tolerance action delay slider to determine how long (in seconds) 

the patient must be out of tolerance before holding the beam. 

Warning 

In case of a beam hold failure (beam remains active while ExacTrac Dynamic indicates 

beam hold), immediately hold the beam via the linac console and do not resume treatment 

until proper functioning of the beam hold function has been verified. 

References Used in Breath-hold Patient Monitoring 

Workflow Step Reference/Target Surface Breathing Target 

Patient monitoring 

Breath-hold Reference Surface 

(acquired on Breath-hold 

Navigation page) 


• During the monitoring workflow step, the target surface is the acquired reference surface at the 

time of image acquisition (shown on Breath-hold Navigation), and called Breath-hold 


• The target level for the respiratory signal is Treatment Level (Reference), which is in line with 

the imaging level and the Breath-hold Reference Surface. 

Breath-hold Gating Status Indicator 

2 

3 

1 

4 

Figure 53 

Breath-hold Gating Status: This indicator provides color-coded information about the surface 

tracking, the respiratory signal and the beam status. If any of the elements is not within expected 

levels (e.g., the patient's surface is out of tolerance because the patient moved), it will be shown 

here. 

No. 

1 

Description 

Respiratory signal status (text and lower half of ring). 

• Gray: Outside parameters set in the Breath-hold Navigation step. 

• Green: Within set parameters. 


TREATMENT 

No. 

2 

and 

4 

3 

Description 

Surface tracking area status. Text and upper half of ring may be gray or red (out of tolerance) 

or green (within tolerance). 

Status of treatment beam on linac. 

• Gray: 

- Treatment beam on linac active, but paused by ExacTrac Dynamic. 

- Treatment beam off. 

• Green: Treatment beam on linac active. 

Beam status. 

• Beam Hold. Circle is gray. 

• Beam Off. Circle is gray. 

• Beam On. Circle is green. 

Warning 

In case of a Beam Hold failure (e.g., beam remains active while ExacTrac Dynamic indicates 

Beam Hold), immediately stop the beam via the linac console and do not resume treatment 

until proper functioning of the Beam Hold function has been verified. 

For further information about different indicator combinations, see the related links. 

Related Links 

Breath-hold Settings on page 73 

Status Information on page 163 


7 BEAM MAPPING 

7.1 About Beam Mapping 

Background 

Beam Mapping is a specific workflow that is only required for the combination of TrueBeam linacs 

and MOSAIQ as an R&V system. In this scenario, the PlanInstance UID of the plan loaded on the 

linac may vary from the one available in ExacTrac Dynamic. To make sure that the same plan is 

loaded on the linac and ExacTrac Dynamic, it is necessary to select a treatment plan and map all 

beams by preparing every single beam on the linac. 

If no plan with the PlanInstance UID of the plan loaded on the linac is available, ExacTrac 

Dynamic checks if a treatment plan with the same patient ID is available. If so, all plans with this 

patient ID are displayed for selection. If no plan with this patient ID is available, the treatment is 

authorized by ExacTrac Dynamic automatically. 

NOTE: If a plan is supposed to be treated without ExacTrac Dynamic (e.g., to a single day 

condition or a patient with the same patient ID is available on ExacTrac Dynamic), it is possible 

to reject and authorize the treatment plan before beam mapping needs to be performed. 

Frequency 

If the clinic has a setup that requires beam mapping, the workflow is enforced every time 

ExacTrac Dynamic does not find the plan that is loaded on the linac (because the UIDs are 

different) or if not all beams were mapped in a previous session. 

This procedure has to be repeated each time a patient treatment plan is modified in MOSAIQ and 

receives a new PlanUID as the existing beam mapping will be invalidated by this. 

How Beam Mapping Works 

For every beam in Varian, beam mapping searches for the corresponding beam in the plan 

selected by the user according to the following properties: 

• Beam Type 

• Beam Name 

• Start Angle 

• Stop Angle 

• Gantry Rotation Direction 

• Couch (patient support angle) 

• Isocenter 

Prepare every beam on the linac to map the beam in ExacTrac Dynamic. Beam mapping 

provides color indicators to show if a beam is unmapped (no color), mapped (green), or cannot be 

mapped (red). Only successfully mapped beams can be loaded and authorized by ExacTrac 


Beam Type consists of either treatment beams or setup beams. The initial list of beams known to 

ExacTrac Dynamic might not include a setup beam. When you start mapping beams, if a setup 

beam is found, it will be added to the ExacTrac Dynamic list (e.g., making the list longer by one 

beam). 


BEAM MAPPING 

In some instances, if two unmapped beams known to ExacTrac Dynamic are very similar (e.g., 

identical except for the number of monitor units), ExacTrac Dynamic will map to the first beam. If 

this is incorrect, select Reset Mapping and map the beams again in a different order. 

How to Perform Beam Mapping 

If you are using MOSAIQ with Varian and the PlanInstance UIDs vary, you must perform beam 

mapping. 

Step 

1. Select ExacTrac Dynamic in Content Manager. 

2. Plan Selection opens. 

All plans available for the patient ID of the plan loaded on the linac are listed in ExacTrac 


Select the plan that matches to the plan on the linac. 

3. Patient Confirmation opens. 

4. Review patient data and plan settings and select Confirm Plan. 

5. 

1 

2 

The Beam Mapping page opens. 

All beams recognized by ExacTrac Dynamic are displayed on the left 1. At this stage, 

no beams are displayed on the right 2. 

6. Select and prepare one of the beams on the linac to start beam mapping. 


About Beam Mapping 

Step 

7. 

1 

Once you have prepared a beam, the beam information is provided by the linac to Exac- 

Trac Dynamic. 

If a matching beam is found, it is displayed with green marks in the middle to indicate a 

perfect match. Beams are indicated as either Setup beams or Treatment beams. 

If you do not want to map any beam (e.g., you have loaded the wrong patient plan), quit 

the software via the Menu. 

8. If the beam was successfully mapped, Confirm Mapping 2 is enabled. 

NOTE: If you select Confirm Mapping before all beams are mapped, and later try to load 

an unmapped beam, a pop-up will warn you that the beam has not been mapped and you 

will not be able to load it. 

9. You can now: 

10. 

• Select a new beam on the linac to continue mapping beams. 

• Select Confirm Mapping 2. 

• Select Reset Mapping 1 to start over. 

2 

If you try to map a beam and no match is found, it is indicated with red in the middle and 

no corresponding beam is shown in the other column. 

11. Continue mapping beams. 


BEAM MAPPING 

Step 

12. 

1 

2 

When you are finished, the status of each beam is indicated 1, 2. 

Select Confirm Mapping 3 to continue. 

3 


8 SYSTEM CALIBRATION 

AND DAILY CHECK 

SURFACE 

8.1 About Performing Calibrations 

Calibration Routine 

Perform all calibrations regularly to ensure that ExacTrac Dynamic performs accurately. Brainlab 

recommends performing the calibrations in the following order and frequency: 

Calibration Application 

Thermal to 3D Camera Calibration 


Frequency 

Once a month 

Periodically, or if system becomes decalibrated (e.g., after 

a component collision or after modifying the system setup) 

Warning 

Perform all calibration steps in order to minimize the difference between ExacTrac Dynamic 

isocenter and linac radiation isocenter. 

• To ensure optimal safety and efficient use of the system, you must perform the Daily Check 

every day prior to clinical use of the system. At midnight, the Daily Check becomes invalid. 

• If you are using iGUIDE, it is recommended to do the iGUIDE calibration before performing 

other calibrations in ExacTrac Dynamic in order to detect misalignment of the lasers. 

• Always perform all calibrations with a warmed-up system. 

Authorized Users 

To perform any calibration procedure, you must have sufficient user rights. 

Each calibration of the system carries the risk of miscalibration. For optimal safety, Brainlab 

recommends only giving expert users the rights to calibrate the system. 

Calibration Limitations 

NOTE: Calibration must be performed at a constant room temperature. 

Warning 

After an update of software or hardware from the linac, always verify that the ExacTrac 

Dynamic calibration is still valid. 


SYSTEM CALIBRATION AND DAILY CHECK SURFACE 

Warning 

Be careful when using equipment with a height greater than 1.8 m (e.g., drip rails) close to 

the surface tracking system, and ask your patients to take special care. Inadvertent 

collision could misalign the system. In such cases, the system must be recalibrated. In the 

case of extreme collisions, contact Brainlab support. 

Warning 

Always calibrate the system after an equipment collision occurs. In the case of extreme 

collisions, contact Brainlab support. 

Warning 

Ensure that the pitch and roll device is at zero/home position prior to performing any 

calibration/QA tasks. 


About 3D Camera Warm-Up 

8.2 About 3D Camera Warm-Up 

Technical Information 

The 3D Camera is subject to two types of warm-up: 

• Power On warm-up: Starts when the camera is powered on (System On LED is green in 

Computer Cabinet). 

• Blue Light Projector On warm-up: Starts when the blue light projector is on. Note that this 

warm-up occurs in addition to the Power On warm-up. 

The effect of both types of warm-up is that a stationary point in the isocenter drifts, with a 

magnitude that may exceed 1 mm. 

According to the two independent types of warm-up, there are three related temperature 

equilibrium states of the 3D Camera (note that depending on the use of the system, the camera 

may also be between the mentioned equilibrium states): 

Thermal Equilibrium 

State 

A 

B 

System Power 

ON for very short time (< ten minutes) 

ON for extended time (> one hour) 

Blue Light Projector 



C ON for extended time (> one hour) ON for extended time (> one hour) 

It takes approximately one hour with blue light projector OFF to return from state C to state B. 

Implications During Clinical Use 

The potential impact during clinical use of the 3D Camera system warm-up behavior is as follows: 

Position accuracy 

The 3D Camera is used to preposition the patient and also to provide information 

about patient movement during treatment monitoring. 

In a typical clinical routine with 10-15 minute treatment slots, the camera 

stays in state B and the blue light projector is turned off between patients. No 

drifts occur. 

A drift caused by camera warm-up behavior does not have an effect on the 

accuracy of the absolute patient position since the final patient treatment position 

is determined by using an external device (e.g., CBCT). 

If the blue light projector is turned on for an extended time, the system 

moves from state B to state C. This may typically be the case for extended 

treatments that last for more than 10-15 minutes. The occurring warm-up 

drift may introduce inaccuracies to the relative tracking of the patient position. 

Recommendations 

To minimize the effects of 3D Camera system warm-up, consider the following recommendations. 

Warm-up Period 

Depending on the environment, a warm-up period of up to one hour may be 

required. 

This ensures that the 3D Camera is in thermal equilibrium state B and not 

subject to any potential temperature-induced, temporary decalibration, which 

could have an undesired effect during the Daily Check. 

ExacTrac Dynamic must be powered (System On) for the corresponding 

time (e.g., up to one hour) before clinical use. 



System Power 

On/Off 

Because the timer module allows the system to be turned on automatically 

before clinical use to ensure proper warm-up of the 3D Camera, Brainlab no 

longer recommends turning off the system only during periods of extended 

inactivity. 

To save energy, the system can be turned off daily after treatments. 


Calibration Workflows 

8.3 Calibration Workflows 

General Calibration Recommendations 

Regular calibration and verification of the system is necessary to ensure accuracy. You must 

perform the Daily Check every day. After mechanical impact to one of its components, perform 

the Daily Check again. 

Warning 

Calibration must be performed according to the calibration instructions. A wrongly 

performed system calibration can lead to ionizing radiation exposure to tissue outside the 

target volume. 



8.3.1 Performing Thermal to 3D Camera Calibration 

About Thermal to 3D Camera Calibration 

ExacTrac Dynamic uses surface detection to determine the exact position of the patient. 

The purpose of the Thermal to 3D Camera Calibration is to ensure that the Thermal Camera is 

calibrated relative to the 3D Camera. Use the Thermal to 3D Calibration Phantom to perform 

calibration. 

Frequency of Calibration 

Perform calibration at least every 35 days. 

How to Heat Up the Phantom 

The Thermal to 3D Calibration Phantom needs about 10-15 minutes to warm up. 

NOTE: The warm-up time may be shortened if the lid is left closed. 

Step 

1. Plug in the phantom and wait until it is warm enough to perform the calibration. 

2. When it is warm enough, position the Thermal to 3D Calibration Phantom on the couch. 

Use the laser engravings on the phantom to position it close to the isocenter. 

3. Leave the phantom plugged in during calibration. 

Warning 

The Thermal to 3D Calibration Phantom needs to be heated before calibration 

tasks can be performed. Using a cold phantom will result in a failed calibration. 

How to Perform Thermal to 3D Camera Calibration 

Step 

1. Ensure that the Thermal to 3D Calibration Phantom is sufficiently warm. 

2. Ensure that the phantom's lid is open before starting calibration. 

3. From Content Manager, open Calibration, then select Thermal to 3D Camera Calibration. 


Performing Thermal to 3D Camera Calibration 

Step 

4. 

1 

Ensure the Thermal to 3D Calibration Phantom is within the camera field of view: The 

software displays a thermal image of the phantom and the markers (left), and a blackand-white 

image of the phantom taken from the 3D camera with cross hairs over the projected 

isocenter (right). 

To help you position the phantom, use the guide mark at the top and the laser marks on 

the sides of the phantom. 

5. Select Start calibration 1. 

6. 

ExacTrac Dynamic starts calibration. 

1 

2 

4 

3 

An image and the calibration result are displayed. Detected thermal markers, shown as 

white circles 1, should correspond with the thermal markers in the image on the left. Detected 

3D markers, shown as white spheres, should correspond with the 3D markers in 

the image on the right. If all markers are correctly detected, Calibration successful 2 

appears below the image. 

7. If calibration is satisfactory, select Save & Exit 3. 



Step 

8. 

If calibration is not satisfactory: 

• Select Start Calibration to perform calibration again. 

• Select Cancel 4 to leave the application. A message is displayed informing you that 

the calibration has not been updated. 

Troubleshooting Thermal to 3D Camera Calibration 

If calibration fails, consider the following reasons and solutions. 

Problem 

Phantom too cold 

Phantom too hot 

Not all phantom markers are 

visible 

Phantom partially covered 

Phantom not close enough to 

the isocenter 

Phantom not visible to camera 

Phantom not plugged in 

Description 

Ensure the phantom is sufficiently warm before performing calibration. 

Warm-up takes about 10-15 minutes. 

Ensure the phantom has not been plugged in too long before 

performing calibration. 

If any phantom markers are not visible to the camera, calibration 

will fail. 

Placement in the isocenter does not need to be precise, but 

may fail if phantom is too far from the isocenter. 

Placement in the isocenter does not need to be precise, but will 

fail if the phantom is not in camera field of view. 

Ensure the phantom remains plugged in during calibration. 


Performing Isocenter Calibration Surface 

8.3.2 Performing Isocenter Calibration Surface 

About Isocenter Calibration Surface 

Isocenter Calibration Surface calibrates the surface tracking system to the linac coordinate 

system and isocenter. For the surface tracking, the detected phantom's surface is used to define 

the system geometry and position. 

Isocenter Calibration Surface can be done using the room lasers, the linac lightfield or an 

external positioning scan (e.g., CBCT). 

NOTE: To compensate the limited setup accuracy of the room lasers and/or linac lightfield, an 

IGRT positioning of the phantom to the linac isocenter is highly recommended. 

Frequency of Calibration 

Perform calibration when the Daily Check fails and/or according to your hospital's calibration 

schedule. 

Prerequisites 

Prerequisites for a successful Isocenter Calibration Surface: 

• Ensure that the System Calibration Phantom is positioned in the isocenter as exactly as 

possible. This may require adjusting the laser or linac crosshair to the linac isocenter. 

Alternatively, to use a scan from an external positioning device (e.g., CBCT) to position the 

System Calibration Phantom at isocenter, a phantom plan must be created. 

• Ensure that the camera is warmed up to temperature state B. For further information, see the 

section about 3D Camera Warm-Up in this user guide. 

The treatment plan must be created based on a good, high-resolution scan of the System 

Calibration Phantom with correct axis alignment. 

• The isocenter of the test treatment plan has to be located in the exact center of the middle 

sphere of the System Calibration Phantom. 

• The external positioning should then position the middle sphere of the System Calibration 

Phantom exactly in the external positioning imaging isocenter. The ExacTrac Dynamic 

calibration will then calibrate the ExacTrac Dynamic isocenter to the external positioning 

imaging isocenter of your linac. 

NOTE: If an external positioning device is used to position the phantom, ensure that the external 

device is calibrated to the linac isocenter. 

How to Position the System Calibration Phantom 

Step 

1. Ensure that the couch is level. 

2. Place the System Calibration Phantom on the couch top. 

3. Align the phantom so it is exactly in the isocenter in regard to position and rotation. 

You can use the lasers, linac lightfield or cone beam for this process. Ensure that the 

used alignment system is correctly aligned to the linac coordinate system and the linac 

isocenter. 

Warning 

Proceed with special care when aligning the isocenter phantom with the 

treatment room lasers. Incorrect isocenter phantom alignment will result in 

incorrect patient positioning. 



How to Perform Isocenter Calibration Surface 

Step 

1. Ensure the couch is level. 

2. From Content Manager, open Calibration & QA, and then select Isocenter Calibration 

Surface. 

Isocenter Calibration Surface opens. Wait until the camera is ready. 

3. Ensure that the System Calibration Phantom is aligned exactly in the isocenter. 

If necessary, move the gantry to a non-obscuring position. 

4. Select Confirm. 

5. 

Adjust the bounding box around the phantom. The box should include the entire phantom 

but exclude everything else (e.g., the gantry). 

6. Start calibration. 

7. 

1 

Surface tracking registers the known geometry of the phantom, which has been positioned 

at the linac isocenter. If successful, the deviation from the last stored isocenter calibration 

is displayed 1. 


Performing Isocenter Calibration Surface 

Step 

8. 

9. 

If the new isocenter position differs significantly from the last Isocenter Calibration Surface 

result, a pop-up is displayed with the deviation. You must select Confirm to continue 

or Cancel if the result is unacceptable. 

After confirming the deviation, select Save & Exit. The new isocenter calibration is saved. 

Troubleshooting Isocenter Calibration Surface 

If calibration fails, consider the following reasons and solutions: 

Problem 

Camera calibration failed 

New isocenter position differs 

significantly from stored isocenter 

calibration 

Description 

Ensure that phantom is correctly aligned to linac isocenter (especially 

rotations). 

Restart calibration. 

Ensure that phantom is correctly aligned to linac isocenter. 



8.4 Daily Check Surface 

Verifying Consistency 

The Daily Check is a consistency check that verifies: 

• That the system setup geometry has not changed. 

• That the phantom's position corresponds with the saved isocenter position (users must confirm 

this). 

The Daily Check is not an indication of the achievable positioning accuracy to the linac isocenter. 

Frequency of Daily Check 

You must perform the Daily Check at least once a day before the first patient treatment. If not, the 

software is blocked until the Daily Check is performed. 

After a mechanical impact to one of the system components, always verify system geometry and 

calibration by performing a Daily Check. 

Prerequisites 

Prerequisites for a successful Daily Check: 

• Ensure that the system used for ExacTrac Dynamic calibration is calibrated to the linac 

isocenter. Depending on the system used for calibration, the Daily Check can be done 

according to laser, linac lightfield, MV imaging or CBCT. 

• Ensure that the camera is warmed up to temperature state B. For further information, see the 

section about 3D Camera Warm Up in this user guide. 

Alternatively, to use the CBCT scan to position the System Calibration Phantom at isocenter, a 

phantom plan must be created. The treatment plan must be created based on a good, highresolution 

scan of the System Calibration Phantom with correct axis alignment. 

• The isocenter of the test treatment plan has to be located in the exact center of the middle 

sphere of the System Calibration Phantom. 

• The CBCT positioning should then position the middle sphere of the System Calibration 

Phantom exactly in the CBCT imaging isocenter. 

NOTE: If the CBCT is used to position the phantom, ensure that the CBCT is calibrated to the 

linac isocenter. 

How to Perform a Daily Check Surface 

Step 

1. From Content Manager, select Daily Check Surface. 

2. Position the System Calibration Phantom on the couch top, exactly at isocenter. Use 

CBCT positioning or the laser marks on the sides of the phantom to line it up with the linac 

axis. 

3. Select Confirm. 

4. Adjust the bounding box around the phantom. The box should include the entire phantom 

but exclude everything else (e.g., the gantry). 

5. Start the Daily Check. 



Step 

6. 

1 

2 

The software checks if the phantom position seen by the camera corresponds to the 

saved isocenter position of the phantom. 

If the check was acceptable, Daily check successful 1 and the translational and rotational 

deviations between the current phantom position and isocenter position are displayed 

in Deviation from isocenter 2. 

Select Quit 3 to save and exit the Daily Check. 

3 

How to Perform an Isocenter Check 

In order to check that the ExacTrac Dynamic isocenter corresponds to the linac isocenter, 

perform positioning of the calibration phantom with an appropriate method (e.g., laser, lightfield, 

CBCT, MV images). Always use the same method for verification that was used for positioning the 

phantom during system calibration. 

Troubleshooting the Daily Check 

If the Daily Check fails, consider the following reasons and solutions. 

Problem 


cannot be 

performed at all 

Check fails 

No valid calibration available 

Incorrect tracking area 

User has not confirmed 

that phantom is aligned to 

isocenter 

Description 

Daily Check cannot be performed without a 

valid calibration. Recalibrate the system. 

The camera calibration failed. Adjust the bounding 

box around the phantom and reacquire images. 

If phantom isocenter position cannot be confirmed, 

recalibrate the system. 

Notes 

Warning 

If the system calibration is interrupted due to any reason, always perform a calibration 

verification (Daily Check) to ensure a valid calibration. If the check fails, a recalibration is 

highly recommended. 



Warning 

If the calculated deviation of the Daily Check exceeds 1 mm in translation (vector length), 

and 1° in any rotational dimension, the verification of the system calibration fails. It is 

highly recommended to invalidate the calibration and recalibrate the system. 

Warning 

The deviations detected during this test are representative of the accuracy you can expect 

during patient treatments. If the deviations shown exceed acceptable values, patients 

should not be treated until the system has been recalibrated. 

Warning 

If the Daily Check fails, recalibrating ExacTrac Dynamic is highly recommended. 

Warning 

For safety reasons, the calibration of the system needs to be verified by Daily Check after 

mechanical impact to one of its components. 

Warning 

For safety reasons, the calibration of the system needs to be verified by Daily Check at 

least once a day before patient treatment is started. 

Warning 


software has been updated. 

Warning 

For safety reasons, after substantial changes to the clinic environment (e.g., building 

construction), verify the system calibration via a Daily Check. 

NOTE: Huge and quick temperature changes during a single treatment can cause an inaccuracy 

in the system. The user must perform calibration verification in case of huge temperature 

changes. 

Daily Check Pass/Fail Criteria 

In addition to confirming that the isocenter was reached, the following criteria must be met in the 

Daily Check: 

Value 

Translation deviation check (vector length) 

1 mm 

Threshold values 

Rotational deviation check (each component) 1° 

Agreement of measured 3D surface point cloud with 3D model 



8.5 Surface Tracking QA 

About Surface Tracking QA 

Clinics using surface-guided radiation therapy (SGRT) are required to ensure its accuracy, safety 

and quality. Users must perform regular quality control tests for acceptance and commissioning on 

a regular basis to ensure optimal system performance. 

Page Overview: Surface Tracking Area Selection 

1 

3 

Figure 54 

2 


1 

Intensity slider 

Based on the external appearance of the object on the 

couch (e.g., color, skin tone), adjust camera intensity using 

the slider on the top, or adjust the settings in Preparation. 

2 Start Tracking Select when the surface tracking area is satisfactory. 

3 

Drawing tools 

Use the brush to draw a Surface Tracking Area. This is 

the area to be tracked. 



Tracking Page 

3 

4 

2 

1 

5 

6 

Figure 55 

No. 

1 

2 

3 

4 

5 

Quit 

Tracking pane 

Surface pane 

Movement pane 

Tracking Quality pane 

Description 

Select to leave the application. Your tracking results will 

not be saved. 

Displays a progress bar with the time recorded and the 

maximum possible recorded length. By default, the maximum 

tracking length is 30 minutes. 

Displays the tracking result via a heat map. 

• Green = 1 mm 

• Red = 10 mm 

The corresponding values are shown in the Movement 

pane. 

Displays the corresponding values for the Surface pane: 

• Distance 

• Lateral 


• Vertical 

• Pitch 

• Roll 

• Yaw 

Quality of tracking. 

• Green = good tracking quality. 

• Red = poor tracking quality. Tracking should be considered 

lost. 

6 Stop Tracking Stop tracking. Tracking results saved to a .json file. 

About .json Files 

The .json file stores tracking results, and includes the following information: 



• The computer name 

• The phantom color setting used (this controls how much blue light is emitted). This information 

corresponds to the options in Preparation: Light, fair, medium or dark 

• The exact time tracking started 

• The time stamp of the result in milliseconds relative to the start of the tracking 

Additional information included: 

• If tracking was lost (e.g., the root-mean-square-error is not sufficient) 

• The root-mean-square error of the 3D surface match 

• The root-mean-square error of the thermal match 

• The tracking shift as a 4x4 matrix (e.g., rotation and translation expressed in matrix form) 

• The tracking shift as 6DoF values (+ distance) 

Notes 

• If the couch is rotated more than 5°, tracking might become less reliable and may cause 

tracking to be lost. 

• If the couch is rotated, tracking is not updated because it takes place during the transition to a 

new PSA. 

• A .json file can be opened with Excel. You can then plot graphs or perform calculations. 

• When you open Surface Tracking QA, a message is displayed that informs you where 

tracking results will be stored if the original path is not available. This path is defined by the 

user as a .bls setting. 

• To display a .json file with formatting, use a coding program (e.g., Visual Studio Code) or use a 

website. 


REVIEWING PATIENT DATA 

9 REVIEWING PATIENT 

DATA 

9.1 Reviewing Patient Data 

Import DICOM RT Data from Third-Party Software 

You can import data from third-party systems. For further information, contact Brainlab support. 

• Data must be transmitted from third-party systems to ExacTrac Dynamic via DICOM push 

using a designated AET 

• The AET is configured by BL-Service and must end with the letters _ARC 

• Pushed data is evaluated for import conversion 

• For RT Elements, It is possible to import third-party DICOM RT data through the "Browse" 

feature of Patient Selection. 

In order to receive the import result in a timely manner, the folder provided via "Browse" should 

best be chosen small, avoiding folders containing multiple exported plans. 

DICOM RT Import Limitations 

There are some limitations for importing third-party DICOM RT data: 

• Beams import is limited to isocenters and beam information 

• Electron-density overrides are currently not imported 

• RT structure set contours of type POINT are currently not imported 

• Spatial registrations are not imported 

• Dose import is limited to physical plan dose 



dicom. 


Repeat Export 

9.2 Repeat Export 

About Repeat Export 

1 

Figure 56 

Use Repeat Export 1 to re-export data (push data to R&V again) and to the PDF treatment 

printout. In most cases, data is exported automatically during the treatment session, but it is 

possible to export patient data later (e.g., in case a network connection was not available). 

How to Use Repeat Export 

Step 

1. From Content Manager, open Repeat Export. 

2. 

A plan selection page opens showing all treated plans (default). 

3. Select a plan for export. 



Step 

4. Select Export. 

5. 

A pop-up is displayed. 



9.3 Archive/Delete Patients 

About Archive/Delete Patients 

Use Archive/Delete Patients to archive and delete patient data on your ExacTrac Dynamic 

system. This is useful for managing patient data and available storage space. 

You can archive or delete patients only via this workflow. 

How to Archive a Patient 

2 

1 

Figure 57 

3 

Step 

1. Start Archive/Delete in Content Manager. 

The Patient Selection page opens. 

By default, patient names are displayed alphabetically, last name first 1. Available storage 

space is also displayed 2. 

2. Select a patient. 

3. Select Archive 3. 

4. 

A dialog box is displayed. 

5. You can now select another patient, delete a patient, or leave the Archive/Delete workflow. 

NOTE: It is not possible to archive multiple patients at once. 



How to Delete a Patient 

Figure 58 

You can delete a patient only if all ExacTrac Dynamic data has already been archived. If a patient 

has not been archived, the delete option is grayed out. 

NOTE: If you have configured the PACs (Archiving Proxy), then you can delete the data without 

archiving it first. In this case, the delete option is available, and data is automatically archived by 

the proxy to the PACs. 

Step 

1. Select a patient. 

2. Select Delete. 

The patient is deleted from the ExacTrac Dynamic system. 

3. You can now select another patient, delete a patient, or leave the Archive/Delete Patient 

workflow. 

NOTE: It is not possible to delete multiple patients at once. 


Generating Treatment Reports 

9.4 Generating Treatment Reports 

Available Reports 

After treatment, the software generates a report that contains a summary for the current session 

for this patient. 

The report is provided in PDF format and can be saved and printed as required. Reports are also 

available for MOSAIQ and ARIA. 

The PDF printout storage location can be partly adjusted to hospital requirements. Contact 

Brainlab support to reconfigure the storage location of the PDF export. 

Contents of the Detailed Report 

The heading of each page shows the treatment date, plan date, patient name and patient ID. It 

also contains: 

• Isocenter 

• Coordinate system 

• Assigned physician 

• Logged-in user 

The different chapters include: 

• Performed workflow. 

• Information from TPS. 

• Treatment data (per beam): Beam data, ExacTrac Dynamic positioning information, surface 

monitoring graph, surface deviation per monitor units applied. 

• Surface data per beam at selected points in time (e.g., when beam is enabled or when surface 

is out of tolerance). 


ALGORITHMS 

10 ALGORITHMS 

10.1 Calibration 

Isocenter Calibration 

The determination of the linac's isocenter position is an important and mandatory calibration. This 

position is the basis for all ExacTrac Dynamic calculations. All distances are displayed relative to 

this point. By using the System Calibration Phantom, the linac isocenter as well as the definition 

of the linac axis is set with the help of the wall lasers or alternatively by CBCT positioning. 

From this point, the system knows the geometric alignment of the linac isocenter and axis in 

relation to the ExacTrac surface system. 


Surface Tracking 

10.2 Surface Tracking 

Principles of Structured Light Scanning 

Surface imaging measures x, y, and z coordinates on a surface, which is then reproduced as a 

map (the depth z is a function of the position x, y). To acquire the surface imaging data, the 

system projects "structured light" in a pseudo-random pattern onto the patient surface. An imaging 

sensor then records the 2D image of the pattern onto the surface. 

• If the surface is flat without any variations in depth, the projected structured light pattern is 

similar to the original projection. 

• If the surface is not flat, the projected structured light pattern appears distorted. 

If the spatial relation between projector and camera is defined, the depth information z can be 

recalculated using the following formula: 

The addition of thermal information is an additional dimension, or virtual topography, allowing for 

higher tracking accuracy. 

Patient Positioning 

1 

Figure 59 

2 

The positioning of the patient surface in relation to the incidence angle of the structured blue light 

from the 3D Camera has a direct impact on the quality of the surface tracking. 

It is disadvantageous for surface tracking if the angle between structured blue light and tracked 

patient surface is very small or even 0° 1. 

To improve the quality of the surface tracking the user should consider different positioning 

possibilities (e.g., elevated through a breast board), as seen in 2. 

Surface Tracking Limitations and Availability of Internal Information 

Surface tracking systems are based on the assumption of a perfect correlation between surface 

and internal organ or tumor motion, since precise, real-time information about internal anatomy is 

generally not available during treatment. A lack of internal information can also compromise the 

calculation of couch shifts. 

SGRT systems can compare and register a live patient surface to a reference surface and 

therefore detect spatial positioning deviations of the patient. Sliding effects (e.g., misalignment of 

the live patient surface with the reference surface) may force the clinician to choose larger regions 

of interest to provide enough topographical information for sufficient surface registration instead of 

smaller, more precise regions which may more closely represent the desired treatment location. 

Using surface registration in conjunction with internal imaging is a crucial verification of the 

accuracy of the surface system for a particular patient and fraction. 


ALGORITHMS 

ExacTrac Dynamic 4D Thermal Camera 

1 2 3 

Figure 60 

ExacTrac Dynamic consists of two kV X-ray tubes mounted on the floor next to the linac, two 

ceiling-mounted flat panel detectors and a single ceiling-mounted 4D thermal camera that 

contains a structured light projector, two high-resolution cameras, and an integrated thermal 

camera. The 4D thermal camera is positioned centrally above the treatment couch, enabling a 

clear field of view during treatment without any risk of occlusions caused by gantry or gantrybased 

imagers. 

The system is used: 

• To roughly preposition the patient before treatment by matching the live 3D surface 1 with the 

reference contour. 

• To perform final positioning based on the stereoscopic X-ray images of internal anatomy using 

the integrated IGRT system. 

• To track intra-fraction patient motion. 

ExacTrac Dynamic combines the 3D and 2D thermal data by projecting the 3D information over 

the thermal image plane, using the perspective-n-point algorithm 2 to calculate a 3D-to-thermal 

matrix used for the projection. This enriches every 3D point (x, y, z) with thermal information T: 

The weighting factor α ensures the comparability between geometric and thermal data and allows 

it to be utilized while matching the reference data P i and the live surface P j 3: 

With every stereoscopic X-ray acquisition, ExacTrac Dynamic records a new reference surface 

including updated thermal information. Sliding effects are reduced. With thermal information, 

ExacTrac Dynamic algorithms achieve more robust matching of live and reference surfaces, 

especially in challenging scenarios (e.g., flat surfaces, small regions of interest). The system is 

able to track the patients’ position with up to 20 frames per second and with a system latency as 

low as 50 ms. This enables ExacTrac Dynamic to trigger a beam hold within milliseconds if the 

patient moves out of tolerance. 


11 APPENDIX 

11.1 Preparation Software Revalidation Workflow 

Background 

This is the recommended system revalidation test for the Preparation software following minor 

changes to your system, including: 

• Operating system hotfixes 

• Installation of virus scanners 

• Third-party software installation 

At least one test DICOM patient should be available for this procedure. 

For major operating system changes (new operating system, new service pack, etc.) contact 

Brainlab support. 

How to Perform Software Revalidation for Preparation 

Step 

1. Start Brainlab Elements. 

2. Select Preparation to start the workflow. 

3. Select an appropriate test patient. 

4. Select a random template. 

5. Check that the patient settings match the selected template. 

6. Change the settings slightly and save the changes. 

7. Close the patient. 

8. Open Treatment. 

9. Select the same test patient. 

10. Review the settings and verify that they match the changes you made earlier. 


APPENDIX 

11.2 Status Information 

General 

Displayed 

Description 

Displayed when something unexpected has happened and ExacTrac 

Dynamic has to recover from an error, such as: 

• The linac rejects a shift that was sent from ExacTrac Dynamic. 

• The couch movement was cancelled or interrupted after the software 

has sent a shift to the linac. 

• The software recognizes that the wrong beam is loaded on the linac 

when trying to approve the treatment. 

Displayed when the user has to be aware that the patient might not be 

in the correct treatment position, such as: 

• The software recognizes an unexpected couch movement. 

• The deviation between the expected patient position and the position 

after performing external positioning differs significantly during the External 

Positioning with X-ray & Surface Monitoring workflow. 

• The patient is out of tolerance but the user chooses to continue the 

treatment (e.g., the user selects Ignore) during monitoring. 

Patient Position Indicator 

Displayed 

Description 

In Tolerance: Displayed when both monitoring systems (X-ray fusion 

and surface tracking) report that the patient position does not differ from 

the planned position by more than the defined tolerance. 

Out of Tolerance: Displayed when surface monitoring detects that the 

patient position is outside the defined tolerance but the time defined by 

the setting Surface out of tolerance action delay is not up yet. In this 

situation, treatment continues. 

When the patient remains outside defined tolerances for longer than the 

time defined, the icon turns red. 

Out of Tolerance (Beam Hold Control off): 

• One of the monitoring systems detects that the patient is not at the intended 


• Beam Hold Control is off. 

ExacTrac Dynamic is unable to hold the beam and treatment will continue. 

To avoid mistreatment, manually stop treatment on the linac. 


Status Information 

Displayed 

Description 

Out of Tolerance (Beam Hold Control on): 

• One of the monitoring systems detects that the patient is not at the intended 


• Beam Hold Control is on. 

In this situation, ExacTrac Dynamic holds the beam until the patient is 

back in tolerance. 

Surface Tracking Lost (Beam Hold Control off): 

• Surface tracking can no longer determine the patient position. 


ExacTrac Dynamic is unable to hold the beam and treatment will continue. 

Stop treatment on the linac and acquire stereoscopic X-ray images to 

reset the tracking region of surface tracking. 

Surface Tracking Lost (Beam Hold Control on): 

• Surface tracking can no longer determine the patient position. 


ExacTrac Dynamic prevents patient treatment until the surface tracking 

recovers on its own or the user acquires stereoscopic X-ray images. 

Fusion Failed (Beam Hold Control off): 

• X-ray fusion is not possible (e.g., X-ray image contrast is insufficient 

for a proper fusion and/or patient moved too much). 


ExacTrac Dynamic is unable to interrupt treatment. 

Ensure that X-ray generator settings (kV and mAs) are correct and acquire 

new X-ray images. Brainlab recommends manually turning off the 

beam on the linac. 

Fusion Failed (Beam Hold Control on): 

• X-ray fusion is not possible (e.g., X-ray image contrast is insufficient 

for a proper fusion and/or patient moved too much). 


ExacTrac Dynamic will interrupt treatment until the X-ray and surface 

camera systems report that the patient is in the correct position. 

Ensure that X-ray generator settings (kV and mAs) are correct and acquire 

new X-ray images. 


APPENDIX 

Breath-hold Gating Status Indicator 

Displayed 

Description 

• Respiratory signal is within breath-hold window. 

• Treatment beam on linac enabled and not held by ExacTrac Dynamic. 

• Surface tracking area within tolerance. 


• Treatment beam on linac off. 



• Treatment beam enabled on linac but held by ExacTrac Dynamic. 

• Surface tracking area out of tolerance. 

• Respiratory signal is not within breath-hold window. 










Status Information 

Displayed 

Description 





APPENDIX 

11.3 System Messages 

System Messages 

The following pages provide system messages you might encounter in ExacTrac Dynamic in the 

different applications.. 

System Messages - All Applications 

Notification / Information 

The current user is not authorized to run this application. The application will be closed. 

ExacTrac is busy... 

Error Messages 

Critical error detected. Safe treatment cannot be ensured. Restart ExacTrac. 

Insufficient performance of the graphical user interface detected. 

An internal error occurs. Contact Brainlab support. 

A background service is not connected at the moment. 

A background service has an incompatible or an invalid version. 

A background service encounters an internal failure. Contact Brainlab support if the problem persists. 

Warnings 

Global patient lock checking failed. 

Patient is currently being prepared or used for treatment by another user. 

Another user has opened the patient for preparation or treatment. 

Failed to export data. 

Failed to transfer exported data. 

System Messages - Calibration Applications 


Acquire X-ray images 

Press X-ray console acquisition button to restart calibration. 

Calibration data not saved. Exit anyway? 

Calibration has not been updated. 

Current calibration is invalid. Recalibrate the system. 

Enable automatic X-ray mode on X-ray console to continue tubes warm-up. 

Enable automatic X-ray mode on X-ray console to start tubes warm-up. 

Enable automatic X-ray mode to restart X-ray Correction Image Acquisition. 

Remove all objects between X-ray tubes and detectors: 

1. Retract couch 

2. Rotate gantry to 90° 

3. Retract all imaging acquisition arms (kV and MV) 

Calibrating: Press X-ray console stop button to cancel. 




Place Thermal to 3D Camera Calibration Phantom in center of 3D Camera view. 

Press 'Save & Exit' to update calibration and close application. 

Remove objects interfering between tubes and detectors. 

Align System Calibration Phantom as accurately as possible with linac isocenter. Consider translations 

and rotations. 

Adjust 3D Camera bounding box to encompass System Calibration Phantom. Acquire X-ray images 

to start calibration. 

Adjust bounding box to encompass the isocenter calibration phantom. 

Make sure phantom is aligned correctly and restart calibration. 

Save new Isocenter Calibration? 

Note: This action will invalidate an existing Radiation Isocenter Calibration. 

Save new Isocenter Calibration? 

Wait until 3D Camera is ready. 

Image saved to 

Press X-ray console acquisition button to restart test acquisition. 

Press X-ray console acquisition button to restart sphere detection. 

Align a radiopaque sphere with Radiation Isocenter. 

Authorization failed. 

Cannot update Daily Check timestamp. 

Ensure that calibration file is not write protected. 

Extend Daily Check Validity 

Enter the treatment room. Is phantom aligned with isocenter? 

Perform warm-up of X-ray tubes? 

Acquire X-ray images to start Daily Check 

Place System Calibration Phantom at isocenter. 

Align System Calibration Phantom as accurately as possible with linac isocenter. This position is 

used for the daily check. 

Make sure phantom is aligned correctly and restart Daily Check. 

Daily Check failed. Select further procedure. 

Press X-ray console acquisition button to restart Daily Check. 

Calibration invalidated. 

Thermal to 3D Camera Calibration may be incorrect. Recalibrate Thermal to 3D Camera? 

System Calibration is incorrect. This may result in patient mistreatment. Continue? 

Daily check failed. This may result in patient mistreatment. Exit without updating daily check? 

Daily check result not saved. Exit anyway? 

Extend Daily Check validity? 

Daily check failed. This may result in patient mistreatment. Extend validity of previous daily 

check? 

Tube warm-up was interrupted. Restart the tube warm-up? 

Select Phantom Color and define Surface Tracking Area. 

New Tracking 

Tracking stopped. Maximum tracking length reached. ${additionalMessage} 


APPENDIX 


Quitting will stop tracking. Tracking results will be discarded. Quit anyway? 

Surface Tracking results automatically saved to: ${folder} 

Error saving tracking results. Your results are temporarily stored in: ${folder} The file will be deleted 

when the application is closed. 

Saving tracking results... 

The calibration failed. See log files for details. 

The calibration was successful and has been saved. 

A severe error occurred. Close the application. 

A settings file is read-only, or the current user is not allowed to modify it. 

Ensure that the user is in the correct Windows user group and contact Brainlab Support if the 

problem persists. 

The application will be closed. 


Failed to write to the folder: ${folder} 

The $ {calb} Calibration is invalid. 

X-ray tubes are overheated. 

X-ray service is currently nonoperational. Trying to recover... 

Warnings 

Authorization failed. Calibration cannot be invalidated. 

Calibration cannot be saved. Ensure that calibration file is not write protected. 

New isocenter position differs significantly from last Isocenter Calibration result (calibrated on: $ 

{timestamp}, calibration status: ${status}). 

Translational deviation (threshold: ${maxTranslation} mm): ${translation} mm 

Rotational deviation (threshold: ${maxRotation}°): Lat: ${rotation_0}°, Long: ${rotation_1}°, Vert: 

${rotation_2}° 

Confirm that System Calibration Phantom is correctly positioned. 

Radiation Isocenter position differs significantly from last isocenter position (calibrated on: $ 

{timestamp}). 

Deviation: ${distance} mm (threshold: ${maxDistance} mm) 

Confirm that radiopaque sphere is correctly positioned. 

System Messages - Preparation Application 


Enter a template name. 

This template name already exists. Select different name. 

Export was successful. 

Export finished with errors. More detailed error messages can be found in the log file. 

Export failed. More detailed error messages can be found in the log file. 

Plan settings were updated to the current version. Please verify the plan settings before saving. 

Plan settings were adapted to the Local Shared Settings. Please verify the plan settings before 

saving. 

X-ray tolerances were adapted to the respective Surface tracking tolerances. Please verify the 

plan settings before saving. 




Patient is currently open in Treatment App. Close patient in Treatment App before modifying it. 

Unprepared patient plan has been loaded on linac. Do you want to save the current plan and 

load the new plan? 

There are unsaved changes. Do you want to save before closing? 

The changes cannot be saved because at least one OAR has to be selected. Do you want to 

continue and discard the changes? 

The changes cannot be saved. Do you want to continue and discard the changes? 

There are unsaved changes. Do you want to save before closing the patient plan? 

Not all isocenters prepared. All changes will be lost when proceeding. Proceed anyway? 

Patient plan is missing required breath-hold contour objects: 

${value_dibh_contour} 

${value_fb_contour} 

.Patient plan can not be treated in breath-hold workflow. 

Patient plan holds multiple breath-hold and/or free-breathing contour objects: 

${value_dibh_contour} 

${value_fb_contour} 

Patient plan can not be treated in breath-hold workflow. 

Saving is in progress. 

Current plan settings will be discarded. Do you want to assign a new template to this patient? 

Failed to archive selected patient. Contact Brainlab support if the problem persists. 

Failed to delete selected patient. Contact Brainlab support if the problem persists. 

Patient plan preparation failed: 

${reasons} 

Reload patient plan and prepare again. 

Contact Brainlab support if the problem persists. 

This patient plan is license dependent. To continue with this patient plan you must have the following 

license(s): ${missingLicenses} 

Close this patient plan and select a different one or change the template to proceed with this patient 

plan. 

Plan has been treated with previous version of ExacTrac Dynamic. No information is available 

whether the Marker Pattern tool has been used. 

The plan has been treated with a previous version of ExacTrac Dynamic. The CT was restricted 

using a VOI. The VOI that was used for the current X-ray/DRR fusion is not available for display. 

Failed to save template. 

Failed to delete the template. 

No patient plan settings available. 

No template assigned. 

Surface tolerances invalid. 

X-ray tolerances invalid. 

Fusion Settings incompatible with selected workflow. 

Select patient plan to reexport treatment data. 

To prepare or edit patient plan settings, select and load the patient plan. 

Select and load patient plan. 

Open Session for Review and Approval. 


APPENDIX 


Select a template to proceed with the import procedure. 

Adjust plan settings if necessary. 

Plan settings saved. 

Define marker in the center of the marker structure in the CT images. 

Define marker endpoints at the outer edges of the marker structure in the CT images. 

Finish defining long markers. Delete the most recently defined marker. 

Invalid number of markers defined. Select both end points of 1 to 5 markers. 

Invalid number of markers defined. Select 2 to 11 markers. 

Changing the marker type will delete all planned markers. Continue? 

Select objects of interest. 

Verify breath-hold reference contours and select at least one OAR. 

Verify breath-hold reference contours. 

Restrict CT volume (VOI). 

Adjust contrast and restrict CT volume (VOI). 

Adjust the contrast between bony and tissue. 

Choose isocenter to prepare. 

Saving patient plan settings... 

Archiving patient. Please wait. 

Deleting patient. Please wait. 

Select master template to initialize new template 

Enter name of new template 

Enter New Template Name 

Are you sure you want to delete template ${templateName}? 

Template updated 

Invalid template name. Note: Only 'a' - 'z' , 'A' - 'Z' , '0' - '9' , '-' , '_' are allowed. 

Template saving failed: 

${reasons} 

Reload template and try again. 

Contact Brainlab support if the problem persists. 

This session does not contain X-ray DRR Fusions. 

Loaded patient plan not valid. Load a valid plan. 

Not supported for Surface Only. 

Not supported for Breathing Management with X-ray. 

"X-ray and Surface" license is not available. 

"Surface Only" license is not available. 

"Breath-hold" license is not available. 

"Respiratory Gating" license is not available. 

"External Positioning" license is not available. 

"Internal Anatomy" license is not available. 

"Implanted Marker" license is not available. 

No message was registered for the message identifier. 




No Templates Available. 

Not supported for beams with couch angle larger than ±${maxPSA}°. 

Warnings 

Connection error. Patient plan settings could not be updated. ExacTrac will update the plan settings 

once the connection is re-established. 

Review if plan settings were updated before patient treatment! 

Technical help: 

Check DICOM Proxy connection. In case the problem persists contact Brainlab support. 

Patient is currently being prepared or used for treatment by another user. Deleting, archiving and 

exporting patient not possible. 

System Messages - Treatment Application 


Beam delivered. Waiting for next beam or patient plan closing... 

Failed to authorize beam. Select/Prepare a beam on linac. 

Turn off treatment beam on linac to start External Repositioning process. 

Deviation from breath-hold target level is now allowed. Consider possible location changes of 

OAR. 

Threshold Exceeded Reference Surface was acquired too far from Imaging Level. This results in 

a deviation from isocenter position during treatment. 

Threshold Exceeded Imaging was performed too far from Planned Level. Patient breath-hold 

level during treatment will deviate from plan. 

Reference Surface was acquired too far from Imaging Level. This results in a deviation from isocenter 

position during treatment. Imaging was performed too far from Planned Target. Patient 

breath-hold level during treatment will deviate from plan. 

Review acquired reference and deviation between levels 

Perform Couch Centering 

Move couch to centered position 

Set imaging marks will be deleted. Continue? 

External imaging needs to be re-acquired to ensure treatment accuracy. Discard existing imaging? 

Reference Surface will be discarded. Continue? 

Select system retrieving shift 

No couch movement detected. Ensure couch is in intended position. 

Move patient to final treatment position 

Apply external imaging shift 

Open "Positional Error" dialog in iGUIDE® 

Compare Shift Values 

Enter Shift Values 

Do not press "Move" in iGUIDE® until you put in the values. 

Guide patient into breath-hold to enable the treatment beam. 

Enable automatic X-ray mode via ExacTrac console. 

New beam loaded on linac. 


APPENDIX 


Beam with different isocenter loaded on linac. 

Modify Area 

The patient plan does not contain any Prepositioning Contour. Position the patient manually. 

Virtual isocenter loaded. Load a treatment beam to proceed. 

Position the patient approximately at isocenter position. 

Patient surface not detected. Manually move the patient closer to treatment position. Verify that 

patient surface matches the reference contour and is not covered. 

Patient surface not detected. Manually move the patient closer to the free-breathing position. 

Verify that patient surface matches the planning CT data and is not covered. 

Select/Prepare beam on linac. 

Verify surface position at time of X-ray acquisition, X-ray quality and X-ray acquisition timing. 

Patient surface not detected. Verify that patient surface matches the planning CT data and is not 

covered. 

Define point for respiratory signal tracking and calculate baseline. 

Baseline computation was not successful. Calculation must be restarted. 

Preposition the free-breathing patient. 

This patient plan is license dependent. To use this patient plan following license(s) is/are required: 

${missingLicenses}. 

Align images to set a start point for the fusion. 

Align images for manual fusion or as a start point for the automatic fusion. 

Mark areas in the X-ray image to exclude them from the fusion. 

Insufficient image information. Reduce the restricted area (ROI) in the X-ray images. 

For automatic fusion, restrict the image information in X-rays (ROI) and/or CT (VOI) to breathdependent 

structures. 

Restrict the CT volume (VOI) to exclude structures from the fusion. 

Carefully verify X-ray image quality. 

Accept the fusion. 

Verify X-ray/DRR fusion. 

Verify and accept the implanted marker fusion. 

Verify fusion result in both, Restricted DRR (VOI) and Full DRR. 

Patient position is out of tolerance. Verify fusion result in both, Restricted DRR (VOI) and Full 

DRR. 

Patient position is out of tolerance. Verify X-ray/DRR fusion. 

Carefully verify the fusion before accepting the externally defined patient position as ExacTrac 

Reference. 

Verify positions of detected markers in X-rays. 

Acquire X-ray images to verify patient position. 

Patient within tolerance. Verify fusion and continue to treatment. 

Modify the 'Bony to Tissue' slider to change DRR generation to your preference. 

For automatic fusion, restrict the image information in X-rays (ROI) and/or CT (VOI) to breathdependent 

structures. 

Verify OAR. 

No patient plan loaded on linac. 




Linac beam already loaded and mapped. 

More than one beam matches the prepared beam on linac. First beam will be chosen. 

Current manual alignment will be taken as final fusion result. 

No automatic optimization will be performed. 

The shift is restricted to 3 DoF. 

Prepare patient plan loaded on linac for treatment with ExacTrac or auto-authorize to treat without 

ExacTrac. 

Patient plan was prepared with an old plan settings version. Reprepare patient plan loaded on 

linac for treatment with ExacTrac or auto-authorize to treat without ExacTrac. 

CT scanner orientation ("${sliceSetOrientation}") differs from patient plan orientation ("${patient- 

Orientation}"). 

Acquire X-rays via console 

Additional messages generated during the treatment: 

Patient plan was unloaded on linac. Close patient plan? 

Quit Treatment App? 

No stereoscopic X-ray images available. It is not possible to proceed in workflow. 

The X-ray generator settings have changed since the last X-ray acquisition. 

Original settings: 

Generator 1: ${image1} 

Generator 2: ${image2} 

Current generator settings: 

Generator 1: ${generator1} 

Generator 2: ${generator2} 

Reacquire new X-ray images or restore the original settings to continue. 

Enable ExacTrac as beam control device on the linac. 

Disable ExacTrac as Beam Hold device on the linac. 

Patient is currently open in Preparation App. Close patient in the Preparation App to continue. 

ExacTrac has recovered from a severe error. Workflow will be restarted to ensure safe treatment. 

Showing DRR with restricted angle(s) for 

${label}: ${compromiseAngle}${unit} instead of ${actualAngle}${unit} 

Setting externally defined position as reference for ExacTrac. 

Detecting Markers 

Fusing Markers 

Setting excluded rotations as monitoring reference: 

${label}: ${zeroAngle}${unit} instead of ${actualAngle}${unit} 

External Positioning (e.g. CBCT) accepted as ExacTrac reference. Continue to treatment. 

Select a patient plan to proceed in the workflow. 

Verify compromise fused DRR. 

Verify compromise fused marker positions. 

Confirm Isocenter 

The PDF generation failed. Go to the Repeat Export workflow to trigger PDF generation again. 

Perform External Imaging (e.g. CBCT) 

Apply shift to move patient to final treatment position. 


APPENDIX 


Plan settings above can only be changed in the ExacTrac Preparation App. 

Changes made to the patient plan settings above will be reset when patient plan is closed in 

Treatment App. 

Changes made to the plan setting above will be reset when a new beam is loaded in Treatment 

App. 

X-ray generator setting changes are only applied to the current couch angle. They will be saved 

for future treatment sessions. 

Changes made to the plan settings above will be saved for future treatment sessions. 

X-ray monitoring not possible 

X-ray generator busy... 

Fast gating condition detected. Treatment has been paused. Press 'OK' to continue treatment. 

Rotate couch to planned treatment position. 

Waiting for linac... 

Loading patient plan... 

Rotate gantry on linac to an angle that allows stereoscopic X-ray acquisitions. 

Daily Check will expire in ${days_left} day(s). 

Saving treatment data... 

Confirm or modify Surface Tracking Area. 

Loaded beam on linac is missing in the patient plan. 

Reason(s): ${details} 

Load a different beam on the linac. 


Loaded beam is inconsistent with patient plan loaded on linac. 

Error occurred during reference surface acquisition. Adapt tracking area and retry to start surface 

tracking. 

Insufficient performance of the surface tracking system detected. 

Insufficient performance of the respiratory signal calculation detected. 

Insufficient performance of the X-ray acquisition detected. 

Insufficient performance of fusion detected. 

Failed to start tracking. Reacquire X-ray images to determine the patient position. 

The Calibration is invalid. Recalibrate ExacTrac. 

The Calibration has expired. Recalibrate ExacTrac. 

The X-ray Calibration time stamp does not match with the time stamp of the Camera Isocenter 

Calibration. Recalibrate ExacTrac. 

The quality assurance check has expired. Perform Daily Check to reenable treatment. 

Patient plan information not available. Unload and load patient plan on linac. 

Session recovery failed. 

The ${calib} Calibration is invalid. 

The ${calib} Calibration is expired. 

X-ray service is nonoperational. Recovering... 

There are no X-ray correction images. Please go to X-ray Correction Image Acquisition and acquire 

correction images. 




No beam loaded. 

No patient plan loaded. 

Unexpected beam loaded - no beam loaded on linac. Load a valid beam on linac. 

Beam not found. 

An internal application error occurred. Contact Brainlab support. 

The desired function is not supported by the linac. 

Gantry operations are not supported by the linac. 

The positioning procedure is not supported by the available iGUIDE version. 

The positioning procedure is not supported by the available ADI version. 

Linac is not responding. Verify network connection and linac status. 

iGUIDE® is not responding. Make sure iGUIDE® is ready for positioning. 

MOSAIQ is not responding. Make sure MOSAIQ and CMA are ready for positioning. 

iCOM interface is not responding. Make sure TCS and iCOM are started properly. 

External Beam Inhibit device is not responding. Restart ExacTrac workstation to solve the problem. 

If problem persists, contact Brainlab support. 

ILK device is not responding. Restart ExacTrac workstation to solve the problem. If problem persists, 

contact Brainlab support. 

ADI interface is not responding. Make sure linac and ADI are configured and started properly. 

Position information from linac is currently not available. Try to perform the workflow again later. 

If problem persists, contact Brainlab support. 

Unexpected linac configuration or behavior is detected. Contact Brainlab support. 

Actual linac machine configured on linac is not consistent with ExacTrac configuration. Contact 


Actual linac machine name from MOSAIQ interface is not consistent with ExacTrac configuration. 

Contact Brainlab support. 

A fatal error of Beam Inhibit device is detected. Contact Brainlab support. 

Actual ADI and DoF configurations are not consistent with ExacTrac. Contact Brainlab support. 

An internal workflow violation was detected. If problem persists, contact Brainlab support. 

The positioning procedure encountered an internal workflow violation. If problem persists, contact 


An internal configuration failure was detected. If problem persists, contact Brainlab support. 

Shift cannot be sent because the target yaw rotation exceeds the linac tolerance. Make sure that 

the couch is at the planned angle and that the patient is correctly positioned on the table, e.g. by 

returning to prepositioning. 

Shift cannot be sent due to unsupported couch tilt mode (3/4 DOF to 6 DoF mismatch). Inspect 

shift values or position patient manually. 

Shift cannot be sent. MOSAIQ and base table can only perform 3 DoF. Inspect shift values or 

position patient manually. 

Shift cannot be sent due to incompatible DoF from available linac and ADI configuration. Inspect 

shift values or position patient manually. 

There is another pending couch movement on linac. 

There is another pending couch movement on MOSAIQ. 

There is another pending couch movement on iGUIDE®. 

Select an appropriate beam on linac and continue with the workflow. 


APPENDIX 


Select an appropriate beam on MOSAIQ and continue with the workflow. 

Missing treatment information from iGUIDE®. Make sure an appropriate beam is loaded on both 

MOSAIQ and iGUIDE. 

Select an appropriate patient plan or beam on linac and try to approve treatment again. 

Select an appropriate beam on MOSAIQ and try to approve the treatment again. 

Open an appropriate patient plan on MOSAIQ and try to approve the treatment again. 

Prepare an appropriate beam on linac and try to approve the treatment again. 

Open an appropriate patient plan on linac and try to approve the treatment again. 

Shift cannot be sent. The request was rejected by the linac. Inspect shift values or any issue on 

linac and then try again. 

Couch movement was interrupted on linac. The expected couch position might not be reached. 

Couch movement was interrupted on iGUIDE®. The expected couch position might not be 

reached. 

Couch movement was interrupted on MOSAIQ. The expected couch position might not be 

reached. 

The couch movement request was cancelled. Make sure to cancel any pending couch movement 

procedure on the linac. 


procedure on the iGUIDE®. 


procedure on MOSAIQ. 

The couch movement procedure is completed but an unexpected position deviation is detected. 

Verify patient position or restart positioning workflow. 

The couch is moved with unexpected deviation. Restart Daily Check workflow. 

A couch positioning procedure has been completed but the couch position gets invalidated due 

to user action on linac. 

A mismatched beam is detected. Select an appropriate beam on linac again. 

Mismatched beam detected due to possible ADI communication failure. Prepare an appropriate 

beam again and continue with the workflow. 

Mismatched patient plan detected. Open an appropriate plan on linac again and continue with 

the workflow. 

Mismatched patient plan from linac detected due to possible ADI communication failure. Prepare 

an appropriate beam again and continue with the workflow. 

Gating device hardware error. Contact Brainlab support. 

ExacTrac gating service has an unhandled error. 

Warnings 

Turn off treatment beam. Inconsistent information about treatment beam state. 

Radiation delivery of less than 2s occurred. This can cause gantry position errors and incorrect 

dose. 

Reestablish surface tracking or modify tracking area to restart surface tracking. 

It seems that after External Positioning (e.g. CBCT) shifts were sent by ExacTrac. 

1. Bring patient into treatment position as defined by External Positioning. 

2. Confirm when patient is in final treatment position. 

Unintended couch move detected. Please return to Prepositioning or move couch to initial position. 



Warnings 

Surface tracking not possible. Treatment beam is on hold. 

Check patient posture. 

Other options: 

Continue without surface tracking (only using respiratory signal). This will be applied for the remaining 

and all following beams. 

OR 

Return to Prepositioning and redefine the Surface Tracking Area. 

Implanted marker positions could not be determined. Turn off treatment beam and verify X-ray 

generator settings. 

One X-ray image has too low contrast. System is performing fusion with only one X-ray image. 

Turn off treatment beam and modify generator settings to improve X-ray images. 

The fusion has failed. Ensure patient is positioned close to isocenter and valid X-ray images are 

available. 

Acquire stereoscopic X-ray images to restart surface tracking. 

If surface tracking does not recover, restart from prepositioning and define a new Surface Tracking 

Area. 

Patient may be treated out of defined tolerances. 


Automatic safeguard will be disabled: 

- No beam hold control by ExacTrac for current beam 

Patient may be treated out of defined tolerances. Automatic safeguard will be disabled: 

- No automatic X-ray triggers for current beam 


Automatic safeguards will be disabled: 

- No beam hold control by ExacTrac for current beam 

- No automatic X-ray triggers for current beam 

Reposition the patient with external device to restart surface tracking. 

The Surface Tracking Area could not be transformed with sufficient quality. A new Surface Tracking 

Area must be defined. 

Invalid respiratory point position. Redefine respiratory point. 

Invalid respiratory point position. Redefine respiratory point and/or verify contour assignment. 

Implanted marker positions could not be determined. Adjust marker positions manually or exclude 

mismatching planned marker(s). 

The fusion has failed. Check that valid X-ray images are available. 

The fusion has failed. Check image alignment in manual fusion settings. 

The fusion has been interrupted. Acquire new X-rays. 

Patient position exceeds hardware limits, values in parentheses cannot be applied completely. 

Manual repositioning of patient is recommended. 

Patient position is out of tolerance. Verify fusion and send shift to continue treatment. 

Error occurred during X-ray acquisition. Reacquire new X-ray images. 

Error occurred during X-ray acquisition. Discard and reacquire X-ray images. 

Breathing signal outside of imaging window. Discard and reacquire X-ray images. 

Turn off treatment beam if treatment is ongoing. Error occurred during X-ray acquisition. Reacquire 

new X-ray images. 

Error occurred during X-ray acquisition. Reacquire new X-ray images. 

No X-ray acquisition possible. Let tubes cool down. 


APPENDIX 

Warnings 

Information contained in one or both X-ray images is insufficient for the fusion. Verify the X-ray 

generator exposure settings. 

Turn off treatment beam. No patient monitoring possible. Return to Monitoring workflow step to 

continue. 

Shift cannot be sent. Ensure that the treatment system is in a state to receive shift. 

Detected marker positions not suitable for X-ray monitoring. 

X-ray fusion will most likely fail during patient monitoring. 

Options: 

- Adjust X-ray generator settings to improve X-ray quality 

- Review marker detection 

- Continue (to avoid failing X-ray fusions, disable automatic X-ray trigger in the menu) 

The number of active markers does not allow a 6 DoF match. A 3 DoF match to the center of 

gravity will be performed instead, excluding rotational correction. 

Correction shift exceeds typical limits. Consider reinspecting the fusion result. 

An unexpected error occurred. Please reload the plan. 

X-ray based monitoring is disabled for Marker Pattern mode. 

Turn off treatment beam. X-ray quality insufficient for patient monitoring. Verify X-ray generator 

settings. 

X-ray tubes were blocked. No acquisition was possible. 

Patient position out of tolerance. 

Continue despite exceeded tolerances? 

Incorrect prepositioning may influence the accuracy of the breath-hold target level calculation. 

Prepositioning Shift Calculation Failed 

Ensure no unwanted structures are included in the Free-Breathing Contour. 

It is possible to continue with manual prepositioning using the live surface information. 

Incorrect prepositioning may influence the accuracy of the Plan breath-hold Level calculation. 

Turn off treatment beam if treatment is ongoing. Patient monitoring and beam hold control not 

possible. Restart ExacTrac if this error persists. 

Large deviation between ExacTrac and External Positioning detected. Ensure that patient is still 

in final treatment position. 

Turn off treatment beam if treatment is ongoing. No X-ray monitoring possible. Let tubes cool 

down. 

No X-rays can be acquired. Let tubes cool down. 

Fusion is not approved. Continue? 

Only 3 DoF positioning possible 

An unexpected couch movement was detected during positioning workflow. Verify patient position 

or restart positioning workflow. 

An unexpected couch movement was detected. Restart Daily Check workflow. 

Define Surface Tracking Area. 

Selected Surface Tracking Area does not provide enough information for reliable tracking. Adjust 

Surface Tracking Area. 

System Messages - Treatment and Calibration Applications 


The following calibration will expire in ${days_left} day(s): ${calib}. 




The X-ray generators are now linked. 

Exposure settings were changed from: 

X-ray Generator 1: ${genExp1} X-ray Generator 2: ${genExp2} 

to: 

X-ray Generator 1&2: ${genExpAll}. 


ExacTrac gating service is temporarily disconnected 

ExacTrac linac service is temporarily disconnected 

ExacTrac X-ray service is temporarily disconnected 

No surface data available or no object detected in camera's field of view. 

Surface tracking failed. 

Unable to connect to the thermal camera. 

Unable to connect to the 3D camera. 

Unable to start image acquisition on the thermal camera. 

Unable to start image acquisition on the 3D camera. 

Unable to start the tracking because there is no valid image available. 

System Messages - Treatment and Preparation Applications 


This feature is disabled when ExacTrac is not run from Content Manager. 

Free Space: ${value} GB (Below Suggested Minimum Free Space) 

Free Space: ${value} GB (Below Required Minimum Free Space) 

The local DICOM Proxy is offline. 

The upstream DICOM Proxy is offline. 

The local DICOM Proxy is not compatible. 

The default export platform is not available. 

There are more slices not part of the imported image data than the allowed setting. 

A newer version of this patient plan is available. 

Patient plan data could not be loaded. 

Not all patient plan data could be loaded. 

DICOM import failed. No DICOM RT plan object available. 

DICOM import failed. No DICOM CT Image Set available. 

Beam includes less than two control points. 

Beam includes no treatment delivery type. 

Beam includes an unexpected treatment delivery type. 

Beam includes no treatment position. 

Beam is missing a patient support angle (PSA) value in at least one control point. 

The Beam has no cumulative meterset weight at all control points. 

Beam includes patient support angle (PSA) changes. 

Beam is missing a gantry angle in at least one control point. 


APPENDIX 


Beam includes invalid gantry route. 

Beam includes a non-zero couch pitch angle. 

Beam includes a non-zero couch roll angle. 

Beam includes no MU per single fraction. 

Beam includes an unsupported patient support angle (PSA) rotation direction. 

Beam includes an unsupported couch pitch rotation direction. 

Beam includes an unsupported couch roll rotation direction. 

The patient plan has no patient orientation. 

The patient plan has no treatment beams, or its beams could not be imported. 

DICOM images are missing in CT Reference set. 

Patient plan data could not be loaded. 

Patient plan settings were removed during loading. 

Patient plan does not contain a Slice Set. 

Patient plan contains a Slice Set with unsupported modality (not a CT). 

Patient Slice Set has an invalid geometry. 

Patient Slice Set has an invalid patient orientation. 

Patient Slice Set has an invalid head-feet orientation. 

Patient plan contains unsupported treatment orientation. 

Patient Slice Set orientation is inconsistent with patient plan. 

Patient slice set has slice distance, which is greater than the allowed maximum distance. 

A beam has more MU than the allowed maximum MU. 

Patient plan has more MU than the allowed maximum MU. 

Patient plan has not been prepared yet. 

Not supported for non-coplanar beams. 

Auto X-ray trigger not supported for consolidated fields. 

Positioning restricted by couch configuration. 

X-ray tubes are blocked for some gantry angles. 

Not all planned X-ray verifications can be acquired. 

Prepositioning Contour missing. 

Patient plan is not prepared or contains invalid number of implanted markers. 

Patient plan was prepared with older version of plan settings. 

Plan settings have changed. 

Warnings 

ExacTrac could not save treatment data. 

Could not save patient plan data. 

A Free-Breathing and a Breath-hold contour are required. 

Prepositioning contour with name "${objectName}" not found. Automatic prepositioning based on 

CT Contour will not be supported. 

Current patient plan is not supported by this template: 

Gantry angle based automatic X-ray triggers are not supported for consolidated fields. 



Warnings 

DICOM Proxy is offline. 

The upstream DICOM Proxy is offline. 

The Archiving Proxy is offline. 

The DICOM Proxy is not compatible. 

The free disk space is low. 

Not enough free disk space available for safe operation. 

Unsaved patient plan data was archived. 


APPENDIX 

11.4 Abbreviations 

Abbreviations Used in this User Guide 

Abbreviation 

3DoF 

6DoF 

CBCT 

CLAHE 

AET 

CTV 

DAP 

DRR 

GTV 

IGRT 

MU 

OAR 

PSA 

PTV 

ROI 

R&V 

SGRT 

VOI 

Meaning 

3 degrees of freedom 

6 degrees of freedom 

Cone-beam CT 

Contrast-limited adaptive histogram equalization 

Application entity title 

Clinical target volume 

Dose area product 

Digitally reconstructed radiograph 

Gross tumor volume 

Image-guided radiotherapy 

Monitor units 

Organs at risk 

Patient support angle (couch angle) 

Planned target volume 

Region of interest (X-ray restriction) 

Record and verify system 

Surface-guided radiotherapy 

Volume of interest 


INDEX 

INDEX 

A 

ADI............................................................................................. 39 

algorithms 

camera calibration................................................................ 159 

isocenter calibration..............................................................159 

archiving proxy 

PACS.................................................................................... 157 

axes 

couch/linac..............................................................................34 

B 

background services 

Elekta integration....................................................................54 

Varian integration....................................................................54 

backup 

protection against data loss....................................................19 

bolus 

physical...................................................................................83 

prepositioning with..................................................................99 

respiratory point....................................................................105 

virtual...................................................................................... 83 

Brainlab customer service.......................................................... 31 

Brainlab service 

user management...................................................................27 

C 

calibration 

isocenter position..................................................................144 

CE label........................................................................................7 

CFS............................................................................................ 39 

console 

Elekta......................................................................................41 

TrueBeam...............................................................................41 

consolidated field sequencing.................................................... 39 

coordinate system 

couch/linac..............................................................................35 

lateral angle............................................................................ 37 

lateral axis.............................................................................. 35 

longitudinal axis...................................................................... 35 

point of origin.......................................................................... 34 

table angles............................................................................ 37 

tilt angles................................................................................ 37 

vertical angle.......................................................................... 37 

x, y, z axes..............................................................................34 

D 

data consistency 

CT scanning........................................................................... 49 

DICOM RT..................................................................................16 

display coordinate system.......................................................... 35 

disposal instructions..................................................................... 8 

duty cycle restrictions................................................................. 39 

E 

Elekta 

60601-1.................................................................................. 20 

beam inhibit............................................................................ 87 

beam release conditions.........................................................87 

console................................................................................... 41 

HexaPOD..............................................................................116 

integration..........................................................................20,39 

multiple isocenters..................................................................77 

pendant...................................................................................41 

Precise Table........................................................................ 116 

prepositioning......................................................................... 93 

shift retrieval......................................................................... 116 

treatment authorization...........................................................87 

virtual isocenters.....................................................................77 

H 

hardware 

shutdown................................................................................ 58 

I 

iGUIDE 

daily check..............................................................................87 

isocenter calibration................................................................. 144 

algorithms............................................................................. 159 

L 

longitudinal angle....................................................................... 37 

M 

MOSAIQ 



O 

operating environment................................................................12 

P 

pacemakers................................................................................13 

PACS 

archiving proxy..................................................................... 157 

passwords.................................................................................. 27 


pdf............................................................................................ 158 

pendant 

Elekta......................................................................................41 

TrueBeam...............................................................................41 

position on couch....................................................................... 44 

positioning 

recommendations................................................................... 44 

positioning accuracy 

CT scanning........................................................................... 49 

prepositioning the patient 

manually................................................................................. 44 

R 

recovery key............................................................................... 27 

registration, evaluation and authorization of chemicals 

REACH..................................................................................... 7 


INDEX 

reports...................................................................................... 158 

rights 


rotational angles......................................................................... 31 

X 


verification............................................................................ 147 

S 

safe disposal................................................................................ 8 

shift tolerance............................................................................. 74 

shutdown 

hardware.................................................................................58 

software.................................................................................. 57 

software 

shutdown................................................................................ 57 

startup.....................................................................................53 

startup 

ExacTrac Dynamic software...................................................53 

support....................................................................................... 31 

support numbers.......................................................................... 5 

surface tracking........................................................................ 160 

sustainability..............................................................................7,8 

T 

thermal camera........................................................................ 161 

third-party software.......................................................................6 

tilt angles.................................................................................... 37 

tracking area 

closed face masks................................................................ 103 

heated blankets.................................................................... 102 

iGuide................................................................................... 102 

subsequent beams............................................................... 102 

troubleshooting..................................................................... 102 

trademarks 

Brainlab.................................................................................... 6 

non-Brainlab............................................................................. 6 

treatment approval 

passwords.............................................................................. 27 

treatment reports...................................................................... 158 

TrueBeam 

console................................................................................... 41 

pendant...................................................................................41 

U 

user console 

shutdown................................................................................ 58 

user logs.....................................................................................27 

V 

Varian 

ADI..........................................................................................39 

automations............................................................................ 39 

couch centering.................................................................... 110 

Hyper ARC............................................................................. 39 

integration...............................................................................39 


MV port film fields................................................................... 39 

shift retrieval......................................................................... 115 

treatment authorization...........................................................87 

unplanned treatment...............................................................39 


verification of X-ray calibration................................................. 147 

W 

warranty........................................................................................8 

waste electrical and electronic equipment (WEEE)......................8 


ainlab.com 

Art-No. 60922-36EN 

*60922-36EN*

EXACTRAC 

DYNAMIC 

EXACTRAC DYNAMIC 

EXACTRAC DYNAMIC SURFACE 

Version 2.0 

System and Technical User Guide 

Revision 1.0 

Date of issue: 2023-11-15 (ISO 8601) 

Copyright 2023, Brainlab AG Germany. All rights reserved.



1 GENERAL INFORMATION.............................................................................................4 

1.1 Contact Data ........................................................................................................................................4 

1.2 Legal Information ...............................................................................................................................5 

1.3 Symbols................................................................................................................................................8 

1.4 Using the System .............................................................................................................................10 

1.5 Compatibility with Medical Devices .............................................................................................14 

1.6 Cybersecurity and Software Environment..................................................................................16 

1.7 ExacTrac Dynamic Network Integration (IEC 80001) ................................................................22 

1.8 User Management.............................................................................................................................25 

1.9 Training and Documentation..........................................................................................................27 

2 HARDWARE OVERVIEW ..............................................................................................29 

2.1 ExacTrac Dynamic Hardware Components ................................................................................29 

2.1.1 4D Thermal Camera ........................................................................................................................30 

2.1.2 Control Room Components ..............................................................................................................31 

2.1.3 Treatment Room Components .........................................................................................................33 

2.1.4 System Control Unit .........................................................................................................................38 

2.1.5 Phantoms.........................................................................................................................................42 

2.1.6 X-ray Components ...........................................................................................................................45 

2.1.7 Radiation Safety...............................................................................................................................60 

2.2 Other Devices....................................................................................................................................61 

3 SYSTEM STARTUP AND SHUTDOWN............................................................62 

3.1 About System Startup and Shutdown .........................................................................................62 

3.2 Starting the ExacTrac Dynamic Software....................................................................................65 

3.3 Restarting the System .....................................................................................................................66 

3.4 Background Services ......................................................................................................................67 

3.5 Shutting Down the Software ..........................................................................................................69 

3.6 Shutting Down the System.............................................................................................................70 

3.7 Overview of Available Applications..............................................................................................72 

2 System and Technical User Guide Rev. 1.0 ExacTrac Dynamic Ver. 2.0


4 CLEANING AND DISINFECTION...........................................................................74 

4.1 Cleaning Guidelines.........................................................................................................................74 

4.2 Disinfection Guidelines...................................................................................................................78 

5 SYSTEM MAINTENANCE.............................................................................................79 

5.1 System Maintenance........................................................................................................................79 

5.2 Aspects and Types of Recurrent Inspections ............................................................................80 

5.3 Authorized Personnel for Recurrent Inspections......................................................................81 

5.4 Warnings and Maintenance Advice ..............................................................................................82 

5.5 Maintenance Schedule ....................................................................................................................83 

5.6 Description of the Maintenance Tasks.........................................................................................84 

5.6.1 Visual Inspection (STI), Monthly .......................................................................................................85 

5.6.2 Functional Test, Monthly...................................................................................................................86 

5.6.3 Accuracy Check, Monthly.................................................................................................................87 

5.6.4 Functional Test (STI), Yearly.............................................................................................................89 

5.6.5 Accuracy Check, Yearly....................................................................................................................92 

5.6.6 Functional Test, Yearly .....................................................................................................................93 

5.6.7 Electrical Safety Measurements (STI) ..............................................................................................95 

5.7 Handling Damaged Equipment....................................................................................................101 

5.8 Returning Damaged Equipment ..................................................................................................102 

6 COMPLIANCES AND SAFETY INFORMATION.....................................103 

6.1 ExacTrac Dynamic System Electronics.....................................................................................103 

6.2 Electromagnetic Compatibility Information..............................................................................106 

7 MAINTENANCE TEMPLATES ................................................................................ 111 

7.1 Maintenance Templates ................................................................................................................ 111 

7.2 Maintenance Task Test Protocol: Monthly, Qualified Clinical Personnel...........................112 

7.3 Maintenance Task Test Protocol: Yearly, Brainlab Support or Brainlab-Authorized 

Support.....................................................................................................................................................114 

INDEX ..................................................................................................................................................116 

System and Technical User Guide Rev. 1.0 ExacTrac Dynamic Ver. 2.0 3

1 GENERAL INFORMATION 

1.1 Contact Data 

Support 

If you cannot find information you need in this guide, or if you have questions or problems, contact 

Brainlab support: 

Region Telephone and Fax Email 

United States, Canada, Central 

and South America 

Tel: +1 800 597 5911 

Fax: +1 708 409 1619 

us.support@brainlab.com 

Brazil Tel: 0800 892 1217 brazil.support@brainlab.com 

UK Tel: +44 1223 755 333 

Spain Tel: +34 900 649 115 

France and French-speaking 

regions 

Africa, Asia, Australia, Europe 

Japan 

Tel: +33 800 676 030 

Tel: +49 89 991568 1044 

Fax: +49 89 991568 5811 

Tel: +81 3 3769 6900 

Fax: +81 3 3769 6901 

support@brainlab.com 

Expected Service Life 

Brainlab provides ten years of service for system components. During this period of time, spare 

parts as well as field support are offered. If the software remains in service after the end of 

support, the cybersecurity risks may increase over time. 

Feedback 

Despite careful review, this user guide may contain errors. Please contact us at 

user.guides@brainlab.com if you have improvement suggestions. 

Manufacturer 

Brainlab AG 

Olof-Palme-Str. 9 

81829 Munich 

Germany 



1.2 Legal Information 

Copyright 

This guide contains proprietary information protected by copyright. No part of this guide may be 

reproduced or translated without express written permission of Brainlab. 

Brainlab Trademarks 

Brainlab ® , Brainlab Connected Care ® , Brainlab Elements ® , ExacTrac Dynamic and ExacTrac 

Dynamic Surface ® are registered trademarks of Brainlab AG or an affiliated company. 

NOTE: See brainlab.com/trademarks for details. 

Non-Brainlab Trademarks 

To the knowledge of Brainlab AG, the following trademark information applies: 

• ARIA OIS, Edge, TrueBeam, VitalBeam and PerfectPitch are registered trademarks of Varian 

Medical Systems, Inc. 

• eBUS is a registered trademark of Pleora Technologies Inc. 

• Elekta, iGUIDE, HexaPOD, MOSAIQ and Response are registered trademarks of Elekta AB. 

• Laird is a registered trademark of Laird Thermal Systems GmbH. 

• Bitlocker, Microsoft and Windows are registered trademarks of Microsoft Corporation. 

• NVIDIA is a trademark and/or registered trademark of NVIDIA Corporation in the US and/or 

other countries. 

• Varex and Varex Imaging are registered trademarks of Varex Imaging Corporation in the US 

and/or other countries. 

Patent Information 

This product may be covered by one or more patents or pending patent applications. For details, 

see: www.brainlab.com/patent. 

Integrated Third-Party Software 

This software is based in part on the following work. Full license and copyright notices can be 

found here: https://blguides.com/third-party-software-licenses 


ACE 6.5.8 LightBurst 1.6.0 



79.1.38+gecefb59 

+chromium-79.0.3945.13 

0 

Merge DICOM Toolkit 5.12.0 

C++ REST SDK 2.10.14 meta 0.1.0 

cryptopp 8.1.0 Modernizr 2.8.3 

d3js 3.5.17 nicescroll 3.6.0 

durandal 2.1.0 node.js 12.13.1 

eigen 3.4.0 Nvidia NVAPI release 367 

Filament 1.4.0 OpenCV 4.7.0 

FTD2XX 2.12.36 openjpeg 2.4.0 




FX11 4.2.0 pdf.js 1.4.20 

ICU 1.8.1 range-v3 0.5.0 

jquery 2.1.4 react.js 16.8.6 

jqueryui 1.11.1 RenderDocAPI 1.4.0 

knockout 3.5.1 requirejs 2.3.5 

LAPACK 3.2.1 SolvOpt 1.2 

libjpeg 2.1.2, 6b UltraVNC 1.3.8.1 

libjpeg-turbo 2.1.2 Xerces-C++ 3.2.3 

LibJpeg16, LibJpeg8 3.6.0, 6b yajl 2.1.0 

LibJpeg2k 2.4.0 zlib 1.2.12 

libpng 1.6.37 Xerces-C++ 3.2.3 

libtiff 3.6.0 

CE Label 

The CE label indicates that the Brainlab product complies with the General Safety 

and Performance Requirements of European Regulation 2017/745, the Medical 

Device Regulation ("MDR"). 

ExacTrac Dynamic is a Class IIb product according to the rules established by 

the MDR. 

Report Incidents Related to This Product 

You are required to report any serious incident that may have occurred related to this product to 

Brainlab, and if within Europe, to your corresponding national competent authority for medical 

devices. 

Registration, Evaluation and Authorization of Chemicals (REACH) 

REACH is the European chemicals law that came into force to improve the protection of human 

health and the environment from risks that can be posed by chemicals. The identification of a 

substance as a substance of very high concern and its inclusion in the candidate list for REACH 

creates certain legal obligations for the importers, producers and suppliers of an article that 

contains such a substance. Brainlab requests suppliers to inform whether and to what extent 

substances from the list are used in their products. For further information regarding REACH 

processes at Brainlab, contact us here: 

www.brainlab.com/reach/ 

Electronic Product Radiation Control (EPRC) Program (US Only) 

According to the EPRC program of the FDA, ExacTrac Dynamic is classified as a medical 

charged-particle radiation therapy system (Accelerator, Linear, Medical), radiation-emitting product 

code IYE. 

Based on 21 CFR (Code of Federal Regulations Title 21) of the CDRH, no performance standard 

is applicable and General Radiological Health requirements apply (21 CFR 1000-1005). 

Packaging and Packaging Disposal 

No special disposal of the packaging material is required. 



Disposal Instructions 

When a medical device reaches the end of its functional life, clean the device of all biomaterial/ 

biohazards and safely dispose of the device in accordance with applicable laws and regulations. 

Only dispose of electrical and electronic equipment in accordance with statutory regulations. 

For information regarding the WEEE (Waste Electrical and Electronic Equipment) 

directive or relevant substances that could be present in the medical equipment, 

visit: 

https://www.brainlab.com/sustainability/ 

https://www.brainlab.com/about-brainlab/technology/weee/ 

Warranty 

Warranties do not apply to products that have been damaged due to accidents, misuse, 

improper reinstallation, or inadequate packaging in the case of return shipments. 

Warranties do not apply to product components that have been modified or replaced 

without the written authorization of Brainlab. 

IEC Compliance 

In accordance with radiation protection, ExacTrac Dynamic is compliant to IEC 60601-2-68:2014. 


Symbols 

1.3 Symbols 

Warnings 

Warning 

Warnings are indicated by triangular warning symbols. They contain safety-critical 

information regarding possible injury, death or other serious consequences associated 

with device use or misuse. 

Cautions 

Cautions are indicated by circular caution symbols. They contain important information 

regarding potential device malfunctions, device failure, damage to device or damage to 

property. 

Notes 

NOTE: Notes are formatted in italic type and indicate additional useful hints. 

Product Symbols 

The below symbols may be found on the system. 

Symbol 

Explanation 

Unique device identifier 

Medical device 

Manufacturer's serial number 

Manufacturer's batch code 

Article number 

Swiss authorized representative 

Manufacturer 

Date of manufacture 

NOTE: The date is expressed as in ISO 8961 as YYYY-MM-DD. 

Consult instructions for use 

U.S. federal law restricts this device to sale by or on order of a physician 



Symbol 

Explanation 

Temperature limit 

NOTE: Indicates the temperature limits to which the medical device can be safely 

exposed. 

Humidity limitation 

NOTE: Indicates the range of humidity to which the medical device can be safely exposed. 

Atmospheric pressure limitation 

NOTE: Indicates the range of atmospheric pressure to which the medical device can 

be safely exposed. 

Follow the instructions for use 

Waste Electrical and Electronic Equipment 

Warning; radioactive material or ionizing radiation 

Warning; electricity 

Hot surface 



1.4 Using the System 

Abbreviated Device Description 

ExacTrac Dynamic (ETD) is a patient positioning and monitoring device used in a radiotherapy 

environment as an add-on system to standard linear accelerators (linacs). It uses radiotherapy 

treatment plans and the associated computed tomography (CT) data to determine the patient's 

planned position and compares it via oblique X-ray images to the actual patient position. The 

calculated correction shift will then be transferred to the treatment machine to align the patient 

correctly at the machine's treatment position. During treatment, the patient is monitored with a 

thermal-surface camera and X-ray imaging to ensure that there is no misalignment due to patient 

movement. Positioning and monitoring are also possible in combination with implanted markers. 

By defining the marker positions, ExacTrac Dynamic can position the patient by using X-rays and 

thereafter monitor the position during treatment. 

Additionally, ExacTrac Dynamic features a breath-hold (BH) functionality to serve as a tool to 

assist respiratory motion management. This functionality includes special features and workflows 

to correctly position the patient at a BH level and thereafter monitor this position using surface 

tracking. Regardless of the treatment indication, a correlation between the patient’s surface and 

internal anatomy must be evaluated with Image-Guided Radiation Therapy. The manually 

acquired X-ray images support a visual inspection of organs at risk (OARs). The aim of this 

technique is to treat the patient only during breath hold phases where the treatment target is at a 

certain position to reduce respiratory-induced tumor motion and to ensure a certain planned 

distance to OARs such as the heart. In addition to the X-ray based positioning technique, the 

system can also monitor the patient after external devices such as Cone-Beam CT (CBCT has 

been used to position the patient). 

The ExacTrac Dynamic Surface (ETDS) is a camera-only platform without the X-ray system and 

is available as a configuration which enables surface-based patient monitoring. This system 

includes an identical thermal-surface camera, workstation, and interconnection hardware to the 

linac as the ETD system. The workflows supported by ETDS are surface based only and must be 

combined with an external IGRT device (e.g., CBCT). 

Intended Purpose 

The device supports radiotherapy and radiosurgery. 

Intended Use and Indications for Use 

ExacTrac Dynamic is intended to position patients at an accurately defined point within the 

treatment beam of a medical accelerator for stereotactic radiosurgery or radiotherapy procedures, 

to monitor the patient position and to provide a beam hold signal in case of a deviation in order to 

treat lesions, tumors and conditions anywhere in the body when radiation treatment is indicated. 

Intended Patient Population 

ExacTrac Dynamic is intended for all patients undergoing Radiotherapy or Radiosurgery 

treatments. There are no physiological limitations or restrictions regarding age, weight, gender, 

etc. 

Intended Part of the Body or Type of Tissue Applied to or Interacted With 

The system consists of many components with different functions and locations. Body contact 

does not affect all components in the same way. 

Most components of the system, like X-ray generators, are out of reach for the user and patient. 

Other components, like covers and units mounted on the ceiling, are not reachable or not meant 

to be touched by users or patients during intended use. 

Body contact is instead expected for the following categories of components: 

• Phantoms, required to calibrate the system, have only user contact. They are handled by the 

user and no patient contact is expected nor foresee. The user picks them up from the storage 



location and positions them where appropriate according to the selected calibration procedure 

and proceed with the calibration or daily check. Optional tools (e.g., X-ray QA support device) 

needed to carry out specific tests can also be included in this category. 

• Electronic interfaces required for the user to interact with the system. No patient contact is 

expected for these components. 

• ExacTrac Dynamic Patient Feedback System is a component of the system that is meant to 

help the patient follow the breathing instructions when using breath-hold functionality. The 

device is firstly clamped to the couch-top by the user and it requires afterwards a fine 

adjustment to reach the desired position. This adjustment can be performed by the user or 

directly by the patient. The adjustment is done by means of handles located at both sides of the 

mirror. As an alternative to this device, the customer is provided also with the article ExacTrac 

Dynamic Patient Feedback Glasses. The article is worn directly by the patient during a BH 

treatment similarly to standard optical glasses. 

Intended User Profile 

The intended users of ExacTrac Dynamic are medical professionals, who are qualified according 

to country and hospital specific regulations to provide (apply) radiation therapy treatments (e.g., 

Radiation Therapist, Radiation Oncologist/Physician, Medical Physicist/Physicist, Dosimetrists). 

ExacTrac Dynamic-specific roles: 

• Radiation Technologist, Technician, Radiographer (MTR) 




- QA task, if they have extended education 

• Medical Physicist (MP): 




- System calibration 

• Radiation Oncologist (RO): 

- Supervise patient's motion monitoring during treatment 

• Patients 

- Adjust and use mirror and user interface for breathing feedback 

Intended Use Environment 

For both ExacTrac Dynamic and ExacTrac Dynamic Surface shall be installed in a treatment 

room within a hospital radiation therapy department. 

ExacTrac Dynamic and ExacTrac Dynamic Surface have a surface-tracking-camera system 

installed in the treatment room. 

For ExacTrac Dynamic two flat panels are mounted to the ceiling and two X-ray tubes are 

embedded in the floor or placed on top of the floor (on-floor installations). 

For both versions the main device used to control ExacTrac Dynamic or ExacTrac Dynamic 

Surface is a console that is located outside of the treatment room. Keyboard and monitor are also 

provided. A touchscreen is mounted inside the treatment room. 

A stable electrical and IT environment (min 1000 Base-T, Latency > 100 ms) is prerequisite for the 

use of ExacTrac Dynamic. 

Environmental conditions are as follows: 








Performance Characteristics 

ExacTrac Dynamic shall provide a translation accuracy better than 1.0 mm and a rotational 

accuracy better than 1.0° for a rigid body. 

The surface deviation shall be better than 1.5 mm and 1° for rigid body. For the breath-hold the 

accuracy shall be better than 2 mm. 

Essential Performance Characteristics 

A 

B1 

B2 

C 

D 

E 

If a surface based deviation between reference and detected patient position is indicated 

and if an allowed tolerance for these values is defined, this deviation is calculated and 

shown with an accuracy of 1.5 mm and 1° for a rigid body. 

If an X-ray and anatomy based deviation between planned and detected patient position 

is indicated, this deviation is calculated and shown with an accuracy of 1 mm and 1° for a 

rigid body. 

If an X-ray and implanted marker based deviation between planned and detected patient 

position is indicated, this deviation is calculated and shown with an accuracy of 1 mm and 

1° for a rigid body. 

Providing shift values to a third-party patient support system as confirmed by the user. 

Providing a "beam hold" signal at the ExacTrac Dynamic hardware output to the thirdparty 

linac within 1s after a deviation between planned and actual patient position exceeding 

tolerance limits was detected. 

Indicating a deviation between actual and planned patient position during breath-hold 

based on surface tracking with an accuracy of 2 mm. 

Contraindications 

ExacTrac Dynamic X-ray imaging radiation, and the therapeutic treatment radiation, can 

potentially have detrimental interaction with active implantable medical devices such as 

pacemakers and active medical devices worn on the body. To prevent injury to patients wearing 

pacemakers or other active implants, the implant manufacturer should be contacted regarding 

possible hazards resulting from radiation exposure. 

Side Effects and Complications 

ExacTrac Dynamic uses ionizing radiation (kV X-ray) with its generally known potential side 

effects of predominantly skin irritation. There are of course known side-effects of radiotherapy. 

However these are associated with linear accelerator treatments in general and not with the use 

of ETD for patient positioning. 

Residual Risks 

There is a danger of ionizing radiation (MV) if the treatment beam is delivered to tissue outside the 

target volume tolerances in cranial or non-cranial mode. If the user does not recognize an 

incorrect fusion due to incorrect shift values (e.g., the user is unable to distinguish between similar 

repetitive structures, such as vertebrae and ribs, in the image fusion), healthy tissue or non-target 

structures could be exposed to substantial unintended radiation. 

Clinical Benefit 

• ExacTrac Dynamic assists clinicians to accurately align the patient to the radiotherapy 

treatment device as defined in the treatment plan. 

• ExacTrac Dynamic assists clinicians to monitor the treatment position of a patient during 

treatment. 



• ExacTrac Dynamic enables clinicians to keep the IGRT imaging dose delivered to the patient 

as low as reasonably possible. 

Careful Handling of Hardware 

System components and accessory instrumentation are comprised of precise mechanical 

parts. Handle them carefully. 

Plausibility Review 

Warning 

Before patient treatment, review the plausibility of all information input to and output from 

the system. 


Compatibility with Medical Devices 

1.5 Compatibility with Medical Devices 

Compatible Brainlab Medical Devices 

ExacTrac Dynamic is compatible with the following Brainlab medical devices. 

Device Name Article Number UDI-DI 

Cranial 4Pi CT Overlay 43420A 04056481144241 

Cranial 4Pi Treatment Overlay 43421A 04056481144234 

Cranial 4Pi Headrest Standard 43440A 04056481144227 

Cranial 4Pi Headrest Low-Neck 43441A 04056481144210 

Cranial 4Pi Headrest Inlay Standard 2pcs 43446A 04056481144203 

Cranial 4Pi Headrest Inlay Openface 2Pcs 43447A 04056481144197 

Cranial 4Pi Headrest Inlay H&N 2Pcs 43448A 04056481144180 

Cranial 4Pi Stereotactic Mask (5 Pcs.) 43450 04056481141936 

Cranial 4Pi Basic Mask (5 Pcs.) 43451 04056481141943 

Cranial 4Pi Open Face Mask (5 Pcs.) 43452 04056481141950 

SRS 4Pi CT Table Overlay 43430 04056481141363 

Cranial 4Pi is an assembly of the following medical device/ accessory groups: 

• Cranial 4Pi Overlays 

• Cranial 4Pi Headrests 

• Cranial 4Pi Headrest Inlays 

• Cranial 4Pi Masks 

The Cranial 4Pi Overlays are medical devices used for fixation of the patient in a CT- resp. linear 

accelerator - environment. 

The Cranial 4 Pi Headrests and the Cranial 4Pi Headrest Inlays are accessories to the Cranial 4Pi 

Overlays to allow an indication specific positioning of the patient's head and neck. 

The Cranial 4Pi Masks are accessories to the Cranial 4Pi Overlays used for producing individual 

custom-made masks for patient immobilization to the Cranial 4Pi Overlay Boards. 

The Cranial 4Pi Immobilization group of devices is used for fixation and repositioning of the 

patient’s head and neck in a CT- and linear accelerator environment. The SRS 4Pi CT Table 

Overlay (43430) is a medical device used for fixation and repositioning of the patient's head and 

neck in a CT-environment. 

The mask sets Cranial 4Pi Stereotactic Mask (43450) / Cranial 4Pi Basic Mask (43451) / 

Cranial 4Pi Open Face Mask (43452) are medical devices used for producing custom-made 

masks for patient fixation to the Overlay Board in a CT- and linear accelerator environment. 

NOTE: For further details, refer to the Cranial 4Pi Hardware User Guide and Cranial 4Pi 

Immobilization Hardware User Guide. 

NOTE: ExacTrac Dynamic is not compatible with Brainlab Robotics. 

Non-Brainlab Medical Devices 

ExacTrac Dynamic is compatible with the following non-Brainlab medical devices only. Do not 

use with any other devices. 

It is a prerequisite that the linac is calibrated correctly. 

For further questions about compatibility, contact Brainlab support. 



Device Description Interface Manufacturer 


TrueBeam Radiotherapy 

System 


TrueBeam Auxiliary 

Device Interface (ADI 

3.0) 

TrueBeam External 

gating interface (EXGI 

2.0) 

Varian Medical Systems, 

Inc. 

3100 Hansen Way 

Palo Alto, CA 94304 

ARIA oncology information 

system 

Record & Verify (R&V) 

System 


COM 


Elekta Linear Accelerator 

MOSAIQ, Patient Positioning 

Systems Interface 

(PPS WebIF) 


Record & Verify System 

Elekta iGUIDE GMI 

Elekta Response gating 

interface 

Elekta iCOM Vx 


COM 

Elekta Limited Cornerstone 

London Road Crawley 

West Sussex RH10 

9BL 

United Kingdom 

NOTE: Brainlab recommends contacting Brainlab support if any linac software or hardware needs 

to be changed or updated. 

Warning 

Brainlab recommends contacting Brainlab support if settings on the linac need to be 

changed after installation. 

Non-Brainlab Devices 

Warning 

Using medical device combinations that have not been authorized by Brainlab may 

adversely affect safety and/or effectiveness of the devices and endanger the safety of the 

patient, user and/or environment. 



dicom. 

DICOM Functionality and Interoperability 

DICOM, by itself, does not guarantee interoperability. However, the conformance statement 

facilitates a first-level validation for interoperability between different applications supporting the 

same DICOM functionality. The conformance statement should be read and understood in 

conjunction with the DICOM standard. 

NOTE: ExacTrac Dynamic requires a DICOM RT data set to perform as intended. 



1.6 Cybersecurity and Software Environment 

Bill of Materials of Integrated Third-Party Software 


ACE 6.5.8 Merge DICOM Toolkit 5.12.0 

AltSoft XML2PDF Formatting 

Engine 

2.1.2.230 meta 0.1.0 

Brainlab Connected Care 1.2.2.4 Modernizr 2.8.3 

Chelsio viewwire 6.16.1.0 nicescroll 3.6.0 



79.1.38+gecefb59 

+chromium-79.0.3945.13 

0 

node.js 12.13.1 

cpprest 2.10.14 Notepad++ 8.5.4 

cryptopp 8.1.0 Nvidia NVAPI release 367 

d3js 3.5.17 Nvidia Quadro Driver 535.98 

durandal 2.1.0 OpenCV 4.7.0 

eBusSDK 3.1.0 openjpeg 1.4.0 

FX11 4.2.0 pdf.js 1.4.20 

eigen 3.4.0 range-v3 0.5.0 

Elekta Gmp 2.1.0 react.js 16.8.6 

Elekta iCOM, iCOMx86 5.14 renderdocapi 1.4.0 

Elekta MSQ 2.0.0 requirejs 2.3.5 

Elekta Responsex86 1.0.13 SolvOpt 1.2 

Filament 1.4.1 SpinnakerSDK 2.7.0.128 

Finder Toolbox NFC 3.6.1 SQLite 3.26.0 

FTD2XX 2.12.36 Thingworx 8.5.18 

ICU 1.8.1 UltraVNC 1.3.8.1 

Intel wired driver 27.7 Varex Viva64 Virtual CP L08 2.2 

jquery 2.1.4 

jqueryui 1.11.1 

kineticjs 5.1.0 

knockout 3.5.1 

LAPACK 3.2.1 

libjpeg 

2.1.2, 6b 

libjpeg-turbo 2.1.2 

LibJpeg16, LibJpeg8 3.6.0, 6b Windows 10 

Varex Virtual CP Software 

Interface 


x86 2008 


x86 2010 


x64 2010 


x64 2012 


x64 2013 


x86 & x64 2015-2019 

L08 2.2 

9.0.30729 

10.0.30319 

10.0.40219 

11.0.61030 

12.0.21005 

14.22.27821.0 

IoT Enterprise 

version 




LibJpeg2k 2.4.0 Xerces-C++ 3.2.3 

libpng 1.6.37 yajl 2.1.0 

libtiff 3.6.0 zlib 1.2.12 

LightBurst 1.6.0 

Cybersecurity Use Environment 

Cybersecurity considerations were made in accordance with the nature of the device, including 

the device type and the use environments of the system during its lifetime. 

The following common best practice security controls ("security hygiene") in the use environment 

are expected to be followed, independently of the status of the system (powered on / powered off): 

• Good physical security to prevent unauthorized physical access to the system. 

If the system is powered on, follow these additional security controls: 

• Access control measures (e.g., role based) to ensure only authenticated and authorized 

personnel are allowed access to network elements, stored information, services and 

applications. 

• Network access controls, such as segmentation, to limit medical device communication. 

• General patch management practices that ensure timely security patch updates on adjacent 

devices in the use environment. 

• Malware protection to prevent unauthorized code execution on adjacent devices in the use 

environment. 

• Ensure that prescribed maintenance is done as required, including installation of security 

patches. 

• Security awareness training of the users. 

Using the device outside of the intended operating environment may lead to cybersecurity 

incidents that may affect safety and effectiveness of the device. 

Hospital administration is responsible for limiting access to the system and the patient data to 

appropriate personnel. 

Be aware that screenshots created by the software contains patient-specific data. Saving the 

screenshot locally thereby saves patient information to the system. 

Warning 

Always follow medical network protection standards. 

Regional Legislation 

In the ExacTrac Dynamic software, patient data is identified by the patient's name and a unique 

ID. For this reason, it must be handled in accordance with the relevant confidentiality legislation 

and protected against unauthorized access. In the United States, patient data must be handled in 

accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

Data Access 

ExacTrac Dynamic receives data via DICOM Proxy from an R&V System. The externally 

accessible DICOM Proxy is located on the Patient Preparation Server. Data is stored within the 

Treatment Workstation or on the Patient Preparation Server. The two DICOM Proxys store data 

on the local file system. Access to this file system is controlled by the hospital via user access 

rights. 

For anonymization of patient data, use a certified third-party product. 

Access to Printouts 

As ExacTrac Dynamic treatment reports contain the patient name and ID, the printer must be 

located in a secure area and the printouts protected against unauthorized access. 



Data Backup 

In order to protect against patient data loss, both patient data folders need to be backed up via 

network or similar. 

Data Protection and System Disposal 

Because confidential patient data is stored on several hard drives or virtually, it is therefore 

necessary to securely erase all workstations and/or server locations where ExacTrac Dynamic or 

the Patient Preparation Server is running or physically destroy the hard drives before system 

disposal. 

Cybersecurity Vulnerability 

If you detect a cybersecurity vulnerability or weakness of the device or if a cybersecurity incident 

takes place involving the device, contact Brainlab support. Depending on the actual event, 

Brainlab support will advise which steps to take. 

Microsoft Security Updates for Windows and Driver Updates 

Brainlab allows the installation of security patches only. Do not install service packs and optional 

updates. Verify your settings to ensure updates are downloaded and installed correctly at a 

suitable time outside of clinical hours. For more information about settings and a list of Microsoft 

Security Updates blocked by Brainlab support, see the Brainlab website (brainlab.com/updates). 

Only perform Windows updates according to the Brainlab website. 

Do not update drivers on Brainlab platforms. Note that automatic driver updates are disabled. 

These shall only be performed by Brainlab support or with Brainlab approval. Neither manual 

steps nor Windows update functionality should be used to update drivers on Brainlab ExacTrac 

Dynamic Workstations. 

Updates 

Updates to the operating system or third-party software should be performed outside clinical hours 

and in a test environment to verify correct operation of the Brainlab system. Brainlab monitors the 

released Windows security updates and will know, for some updates, if problems can be 

expected. Contact Brainlab support if any problems to operating system security updates are 

encountered. 

Virus Scanning and Malware 

If the system is connected to a local area network (LAN), Brainlab recommends using malware 

protection software (e.g., virus scanner) and keeping the definition files up to date. Be aware that 

the malware protection settings can affect system performance (e.g., if each file access is 

monitored, patient data loading and saving might be slow). Therefore Brainlab recommends 

disabling real-time scans and regularly performing virus scans during non-clinical hours using an 

administrative account. 

The default Windows virus scanner, Microsoft Defender, is installed and active. 

Other anti-virus protection can be used if it does not block the communication between ExacTrac 

Dynamic and the associated hardware. The anti-virus software has to have the option to not 

interfere with the network communication between the 3D Camera, the Thermal Camera, Flat 

Panel Detectors and the treatment application (e.g., by enabling firewall exceptions). 

Requirements 

• Do not update the virus scanner software during treatment. 

• The virus scanner must not perform a hard disk drive scan during patient treatment. 



• Do not use the virus scanner in a high security mode during treatment. 

• During scans of the ExacTrac Dynamic folder (D:/Brainlab and E:/Patient), do not delete 

any files or put any files into quarantine. 

Configuration 

Brainlab recommends: 

• Configure the anti-virus software so it does not modify: 

- D:\Brainlab 

- E:\Patient 

- D:\RVExport\ 

- %userprofile%\AppData\Local\Brainlab 

• Deactivate any other anti-virus software feature such as browser/email-scanners, additional 

firewall, etc. 

Compatible Brainlab Software 

Only Brainlab software specified by Brainlab may be installed and used with the system. Contact 

Brainlab support for clarification regarding compatibility with Brainlab software. 

Non-Brainlab Software 

Only authorized Brainlab employees may install software on the Brainlab system. Do not 

install or remove any software applications. 

Information for Hospital Medical IT Network Risk Manager 

The following information is intended for the hospital Medical IT-Network Risk Manager. 

1. 

2. 

3. 

Item 

Purpose of the connection 

to the IT network 

Required IT-network characteristics 

Required IT-network configuration 

Description 

The Brainlab device can load and save patient data. 

These are transferred via DICOM Proxy from ExacTrac 

Dynamic to R&V, linac. 

The Brainlab device transfers medical imaging data and 

patient data between ExacTrac Dynamic and the Patient 

Preparation Server or between the Positioning and 

ExacTrac Dynamic applications via the local DICOM 

Proxy. 

The DICOM Proxy on the Patient Preparation Server also 

transfers medical images and data to the R&V systems 

or linac. 

The average size of a medical imaging data set transferred 

through the network is 100 - 500 MB. 

Required: 

• User management is achieved by joining the Brainlab 

device to the hospital domain and adding users to 

dedicated user groups with group management. 

• Brainlab offers remote system support which requires 

internet access. 

The Brainlab device requires firewall permissions for the 

services listed under point 4, below. 

4. 

Technical specifications of 

the network connection, including 

security specifications 

The Brainlab device includes the following network connections 

(4.1 - 4.8): 



4.1 

4.2 

4.3 

4.4 

4.5 

4.6 

Item 

Physical connection of the 

Brainlab device 



other Brainlab devices or 

hospital file storage 



hospital domain controller 





the Brainlab system and 

other linac (Varian) 



other linac (Elekta) 

Intended information flow 

between the Brainlab device 

and the IT network 

Description 

The system is connected to the IT-network with a 

100/1000 Base-T connection. 

• Recommended speed is 1 GBit. Minimum speed is 100 

MBit. 

• Network latency must be less than 100 ms. 

• The network must be fully switched on. 

• Protocols: CIFS 

• Ports: 445/TCP/in- and outbound 

• Protocols: Microsoft-DS, Kerberos, LDAP, DNS 

• Ports: 445/TCP/UDP/outbound, 88/TCP/UDP/ 

outbound, 389/UDP/outbound, 53/TCP/UDP/outbound 

• Protocols: Brainlab Connected Care 

• Ports: 443/TCP/outbound to: support.brainlab.com, 

gas-aus.axeda.com, ghjap1.axeda.com, ghsj1.axeda.com, 

ghsom1.axeda.com, ghuk1.axeda.com 

• Protocol: ADI (Auxiliary Device Interface) 

• Port: 56050/TCP/in- and outbound 

• Protocol: Elekta protocol 

• Port: 135, 1801, 2101 /TCP/in- and outbound 

The Brainlab device typically consists of the following information 

flow: 

5.1 User authentication 

User authentication at the Brainlab device is processed 

with the help of local user accounts or the hospital domain 

controller. 

5. 

5.2 

Loading of medical imaging 

data 

Medical imaging data is transferred via DICOM Q/R or 

pushed between the R&V. 

5.3 

Storing of modified medical 

imaging data 

Modified medical imaging data is stored on the local hard 

drive or hospital network shared drives. 

5.4 

Patient positioning and 

beam approval 

ExacTrac Dynamic and the linac system perform internal 

communication for patient positioning and beam approval. 

5.5 

Remote support through 

Brainlab 

Remote support for the Brainlab device requires a connection 

to the Brainlab support servers. 

6. 

Hazardous situation resulting 

from an IT-network failure 

A failure of the IT Network connection can cause that the 

treatment cannot be continued or must be repeated. This 

can lead to unnecessary KV Imaging of the patient. 

The following documents are available upon request: 

7. 

Technical descriptions and 

technical manuals 

• Preinstallation manual 

• FDA and CE declarations 

• DICOM conformance statements: (www.brainlab.com/ 

dicom) 

8. 

Recommended product 

configurations 

The Brainlab device will be installed and configured according 

to customer needs by the Brainlab service engineer. 

Subsequent modifications can affect the safety and 

effectiveness of the product. 

9. 

Known incompatibilities and 

restrictions 

The Brainlab device requires a network supporting IPv4. 



10. 

Item 

Product corrective actions 

and recalls 

Description 


anomalies. 

11. Cybersecurity notices 


cybersecurity issues and provide software updates accordingly. 

12. 

Background according to 

IEC 60601-1 3rd edition, 

chapter 14.13 (Connection 

of PEMS by NETWORK/ 

DATA COUPLING to other 

equipment) 

Connecting the Brainlab device to networks that include 

other equipment could result in previously unidentified 

risks to patients, operators or third parties. The responsible 

organization should identify, analyze, evaluate and 

control these risks. Subsequent changes to network 

could introduce new risks and require additional analysis. 

Changes to the network include: 

• Changes to the network configuration 

• Connection of additional items to the network 

• Disconnecting items from the network 

• Updating equipment connected to the network 

• Upgrade of equipment connected to the network 

Warning 

Do not use Brainlab Connected Care during linac Beam On. 



1.7 ExacTrac Dynamic Network Integration (IEC 

80001) 

Ensuring a Safe IT Network 

• Ensure a safe network connection during transferring patient data and during treatment. 

Minimum network specifications are defined by Brainlab. 

• Only install release updates from original manufacturers. 

• After the ExacTrac Dynamic and the linac installation, both systems must have dedicated, 

static IP addresses. Do not use dynamic IP addresses. 

• A stable, reliable and safe network environment and connection are required to guarantee a 

safe and effective use of the ExacTrac Dynamic system when ExacTrac Dynamic is 

connected to a network. Network problems during patient data transfer or patient treatment can 

interrupt the workflow and cause a repetition of parts of the treatment such as X-ray imaging for 

patient position. 

Standard Integration 

The following image shows a typical network setup for a standard ExacTrac Dynamic: 

1 

10 

2 

3 

11 

4 

5 

6 

7 

8 

9 

Figure 1 



No. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

Description 


Varian/ADI 


DICOM Data 


sites) 

Hospital R&V 

Internet 

Remote Access 


Linac Network 

Linac 



Elekta Integration 

The following image shows a typical network setup for ExacTrac Dynamic with an Elekta 

integration: 



10 

3 

11 

2 

1 

4 

5 

6 

7 

8 

9 

Figure 2 

No. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

Description 


Elekta Firewall 


DICOM Data 


sites) 

Hospital R&V 

Internet 

Remote Access 


Elekta Network 

Linac 





1.8 User Management 

Windows Users 

The following Windows users are implemented by default in ExacTrac Dynamic: 

User Group Windows OS Permissions BL User Groups 

Administrator 


BL Service Administrator rights BL_ET_Service 

EmergencyUser 



Power user rights 

BL_ET_Therapist 

BL_ET_TherapistRestricted 

Approver Power user rights BL_ET_Physician 

Physicist Power user rights BL_ET_Physicist 

• To use ExacTrac Dynamic, the user needs power user rights as a minimum. 

• Do not use accounts with administrator rights for treatment tasks. 

• Upon request, hospitals can have an emergency user/generic user account set up. It should 

only be used to access the system in case of an emergency. The hospital IT administrator is 

responsible for communicating the account information to the relevant employees. 

• Service tools and BL Service accounts are intended solely for Brainlab service and must not be 

used while treating patients. 

NOTE: Only members of the Windows user group Administrator can add, modify or delete user 

accounts. The Administrator account is preconfigured by Brainlab support and cannot be deleted. 

If your hospital needs to designate additional roles of user rights other than the standardized 

roles, Brainlab support must add the roles. For further information, contact Brainlab support. 

Windows Login and User Logs 

• The Windows login defines the user rights for the password-protected ExacTrac Dynamic user 

login. The hospital is responsible for administration of passwords and user logins. 

• Every ExacTrac Dynamic user login and ExacTrac Dynamic patient opening and closing 

event is logged and saved in an encrypted log. To access this information, contact Brainlab 

support. 

• In case of a technical or clinical issue with ExacTrac Dynamic, the folder "Log Files" shall be 

zipped and provided to Brainlab support. 

• Manually lock any account that has not been used for more than three months, except for 

Brainlab service. It is recommended to check for unused accounts at least every six months. 

Configuring Rights and Passwords 

Users must access ExacTrac Dynamic with a personal user name and password. User accounts 

have varying permissions, divided into roles. Upon setup, Brainlab support will create the following 

standardized roles: 


User Management 

Role 

Task 

Treatment preparation 

Treatment 

Fusion approval 


Camera calibration 

Template editor 

ET_SuperUser ✔ ✔ ✔ ✔ ✔ ✔ 

ET_Physicist ✔ ✔ ✔ ✔ ✔ 

ET_Physician ✔ ✔ ✔ ✔ 

ET_Therapist ✔ ✔ 

ET_TherapistRestricted 

✔ 

ET_Service ✔ ✔ ✔ ✔ ✔ ✔ 

When assigning rights to new users, adhere to the principle of least privilege (e.g., only assign 

rights that are needed). 

Your hospital IT administrator can configure selected users as registered users with: 

• Approval rights so that image fusion can be approved (e.g., physicians for billing purposes) 

• Calibration rights (e.g., for physicists) 

• Basic rights for standard users (e.g., such as therapists) 

NOTE: Personnel who are still in training are typically assigned ET_TherapistRestricted. 

Accessing Password Settings 

Only the hospital IT administrator can change or reset a password. 



1.9 Training and Documentation 

ExacTrac Dynamic Installation and Preplanning Information 



Brainlab Training 

Before using the system, Brainlab recommends that all users should participate in a training 

program held by a Brainlab representative to ensure safe and appropriate use. 

Supervised Support 

After a sufficient number of complete procedures have been successfully simulated, and following 

a rigorous quality assurance review, the system can be used in selected treatments. 

A Brainlab representative should be present at such treatments to provide medical staff with 

supervision and guidance where necessary. 

Numerical Values Used in This User Guide 

In this user guide, all values and parameters describing imaging performance use standardized SI 

units: metric, Gy, mm and Gy*mm 2 . 

With the exception of angular measurements (indicated by the ° symbol), all numerical values 

displayed by ExacTrac Dynamic are in millimeters (mm). 

Responsibility 

Warning 

This system solely provides assistance to the physician and does not substitute or replace 

the physician's experience and/or responsibility during its use. It must always be possible 

for the user to proceed without the assistance of the system. 

Only trained medical personnel may operate system components and accessory instrumentation. 

Reading User Guides 

This guide describes complex medical software or medical devices that must be used with care. 

It is therefore important that all users of the system, instrument or software: 

• Read this guide carefully before handling the equipment 

• Have access to this guide at all times 

Available User Guides 

Available user guides vary depending upon your configuration. If you have questions regarding 

the user guides you received, please contact Brainlab support. 

User Guide 

ExacTrac Dynamic Elekta Linacs Site Planning 

Manual 

ExacTrac Dynamic Varian Truebeam Linacs 

Site Planning Manual 

Description 


for use with Elekta linacs 


for use with Varian Truebeam linacs 


Training and Documentation 

User Guide 

ExacTrac Dynamic Clinical User Guide (all 

workflows) 

ExacTrac Dynamic Clinical User Guide (ExacTrac 

Dynamic Surface workflows) 

ExacTrac Dynamic System and Technical 

User Guide 

Description 







Detailed information on system setup, technical 

information on the system, specifications and 

compliances 

Additional Documentation 

For further information about X-ray components, see the following documents. 

Device Document Manufacturer 

Housing Data sheet "Housing B-130" Varian Medical Systems 

Tube 

Data sheet "G-892" 

(Varex Imaging Corporation only for the 

X-ray tubes) 

HV Cables 

Data sheet "CA1-type Connector" 

"L3-type cable" 

Claymount 

Collimator This user guide Brainlab 

Generator 

Operating instructions "EDITOR 

Hfe" 

Service manual "EDITOR Hfe" 

Spellman High Voltage Electronics 

GmbH (formerly K&S Röntgenwerk) 

Customer Acceptance Test 

The accuracy of the specific system being used is outlined in the customer acceptance test. 


HARDWARE OVERVIEW 

2 HARDWARE OVERVIEW 

2.1 ExacTrac Dynamic Hardware Components 

About ExacTrac Dynamic Hardware Components 

The ExacTrac Dynamic system is available in different configurations and versions depending on 

your selected hardware and linac manufacturer. The following table shows which hardware 

components are installed depending on the selected configuration. 

Hardware Components 

ExacTrac 

Dynamic 

ExacTrac 


Surface 

See 

4D thermal camera ✔ ✔ Page 30 

Control room components ✔ ✔ Page 31 

Treatment room components ✔ ✔ Page 33 

System control unit ✔ ✔ Page 38 

Phantoms ✔ ✔ Page 42 

X-ray components ✔ Page 45 



For installation and preplanning information and requirements, see the ExacTrac Dynamic Elekta 

Linacs Site Planning Manual and the ExacTrac Dynamic Varian Truebeam Linacs Site 

Planning Manual. 


4D Thermal Camera 

2.1.1 4D Thermal Camera 

About the 4D Thermal Camera 

1 

2 

3 

Figure 3 

No. 

1 

2 

3 

Description 

Stereoscopic low latency data camera lenses 

High definition structured light projector 

Integrated thermal camera lens 

NOTE: Ensure that the camera system is not touched by anyone or anything while ExacTrac 

Dynamic is in use. Users may not affix or deposit anything onto the camera (e.g., blankets, cloth, 

medical equipment). 

NOTE: Users who requested that the camera be installed at a divergent position (e.g., not 0°) 

must be aware that: 

• A divergent camera position could cause limited visibility of some body parts and therefore 

potentially limit performance. 

• Later upgrades/new or upgraded features of ExacTrac Dynamic may not be compatible with 

divergent (i.e., not 0°) camera positions. 


NOTE: Users and patients must not look directly into the light emitted by the camera. 

NOTE: Patients who may be sensitive to blue light should close their eyes during treatment. 

Warning 

Users and patients with a known history of photosensitivity may experience photic- and 

pattern-induced seizures (PPIS) during the use of ExacTrac Dynamic. It is the responsibility 

of the physician in charge to decide how to proceed in such a situation. 



2.1.2 Control Room Components 

About Control Room Components 

ExacTrac Dynamic includes a console for remote control of the X-ray Generator as well as a 

Control Room Monitor, mouse and keyboard. 

ExacTrac Console 

2 

3 

4 

5 

1 

6 

7 

8 

9 

Figure 4 

No. Component Description Relevant Configuration 

ExacTrac 


ExacTrac 


Surface 

1 

Fluoro sequence 

start 

Start an X-ray fluoroscopic sequence. Indicator ring is illuminated 

in green when a fluoroscopic sequence can be 

started. 

✔ 

2 System On Starts the system. ✔ ✔ 

3 

4 

System standby indicator 

System power indicator 

Indicates in green when the system is on. ✔ ✔ 

Indicates in orange when building power is available. ✔ ✔ 

5 System Off Shuts down the system. ✔ ✔ 

6 

Fluoro sequence 

stop 

Stops an X-ray fluoroscopic sequence. Indicator ring blinks 

orange when a fluoroscopic sequence is running. 

✔ 

7 

Radiation warning 

light 

Illuminated when an X-ray image is taken. 

✔ 

8 

9 

X-ray image acquisition 

Takes an X-ray image. Indicator ring is illuminated in green 

when an X-ray image can be taken. 

Currently no supported function with ExacTrac Dynamic. 

✔ 

X-ray buzzer Beeps when an X-ray image is taken. ✔ 


Control Room Components 

Control Room Monitor, Mouse and Keyboard 

Figure 5 

Component 

Description 

Screen size 

24.1" (518.4 x 324.0 mm) 

Resolution 

1920 dots x 1200 lines 

Pixel pitch 

0.270 x 0.270 mm 

Display colors 

8-bit, 16.77 million colors 

Viewing angle (H / V, typical) 178° / 178° 

Luminance (Typ.) 350 cd/m 2 

Contrast ratio (Typ.) 1000 : 1 

Color depth 




2.1.3 Treatment Room Components 

About Treatment Room (In-Room) Equipment 

ExacTrac Dynamic includes an In-Room Monitor (wall- or ceiling-mounted). Depending on your 

configuration, the Patient Feedback System and Patient Feedback Glasses are additional 

hardware components of the ExacTrac Dynamic system for use during breath-hold workflows. 

In-Room Monitor 

1 – 8 

Figure 6 

Component 

Screen size 

Resolution 

Description 

24.1" (518.4 x 324.0 mm) 

1920 dots x 1200 lines 

Aspect ratio 16:10 

Pixel pitch 

Display colors 

0.270 x 0.270 mm 


Viewing angle (H / V, typical) 178° / 178° 

Luminance (Typ.) 350 cd/m 2 

Contrast ratio (Typ.) 1000 : 1 

Color depth 


The In-Room Monitor provides software control via touch interface in the treatment room. The 

monitor can be attached to the treatment room wall or to the treatment room ceiling. 

To avoid patient or operator harm due to collision, always bring ceiling-mounted monitors into a 

parked position. Be careful to avoid collision with any other equipment while positioning the 

monitor. 

No. 

1 

2 

3 

4 

Component 

Power button 

Menu/enter button 

Exit/input button 

Left button 


Treatment Room Components 

No. 

5 

7 

8 

Component 

Right button 

Port A button 

Port B button 

About Attaching the Monitor 

1 

2 

Figure 7 


1 

2 

Ceiling-Mounted Monitor 

Arm (standard) 

Wall-Mounted Monitor Arm 

(optional) 

Monitor can be moved to a convenient position for user 

interaction or moved out of the way if not in use. 

1884 mm x 734/1134 mm x ~100 mm 

292 mm x 122 mm x 122 mm 

Wall channel: 483 mm x 102 mm x ~ 20 mm 

NOTE: If you request an extension of the vertical movement range (e.g., in order to get the 

ceiling-mounted monitor completely out of the way when not in use). You must be aware that the 

monitor or monitor arm may collide with the 4D Thermal Camera, which must be recalibrated 

after any collision. 




Figure 8 

Component 


Description 

The Patient Feedback System allows the patient to see 

the feedback software displayed on the In-Room Monitor 

display. The Patient Feedback System consists of a 

mirror with a flexible arm to position it as well as a screw 

clamp to attach the arm to the couch. 


Treatment Room Components 

Couch Top Screw Clamps 

Figure 9 

Brainlab supports the use of the device with rectangular couch tops that have two parallel flat 

surfaces at a clamping distance of 28 to 50 mm. The device can be also used on non-rectangular 

couch tops if the clamping volume is not farther than 62 mm from the couch head's edge. 

Some examples are: 

• Varian IGRT Couch Top 

• Brainlab Imaging Couch Top 

• Civco MTIL6669 - Universal Couchtop Long Extension, Rectangle, 36.6" (92.9 cm) 



• Elekta iBEAM evo Couchtop (e.g., CA, EP) 

• Elekta iBEAM evo Extension 650 (P10105-423) 

• Elekta HexaPOD evo Extension Long (P10105-426) 

• Elekta Connexion Imaging Module (P10105-210) 

• Elekta Connexion Lateral Opening Module (P10105-241) 

• QFIX kVue Standard Insert (RT-4551KV1) 

• QFIX kVue Short Insert (RT-4551KV2) 

• QFIX kVue Calypso Insert 

Patient Feedback Glasses 

Figure 10 



The Patient Feedback Glasses are an alternative to the mirror system. It consists of a pair of 

eyeglasses with prisms mounted at a 60° angle on the eye pieces that show the image without 

flipping or rotating the reflected image and allows the patient to see the feedback software 

displayed on the In-Room Monitor display. 

A cleaning cloth and a protective case are included. The composition of the cleaning cloth is 80% 

polyester, 20% nylon. 

In general, the device can also be worn in combination with standard optical glasses. 

NOTE: Some users who wear glasses may not be able to use the Patient Feedback Glasses 

because of the size and shape of their standard optical glasses. 


System Control Unit 

2.1.4 System Control Unit 

About the System Control Unit 

1 

Figure 11 

2 

The standard ExacTrac Dynamic configuration includes the following components. 


1 Treatment Workstation Contains various operating and connection interfaces. 

2 

Computer Cabinet 

Not shown 

Contains the Treatment Workstation together with Power 

Distribution Unit, Control Interface Unit, power cables, 

electrical safety devices, etc. 

System internal power and data cables between components 

via building structure. 

Additional elements included within the Control Interface Unit (CIU) and Power Distribution 

Unit are described on the following pages. 

The air conditioning system must be able to maintain a constant room temperature. 

The Treatment Workstation should be shut down at least once every week and preferably at the 

end of each workday. 

ExacTrac Dynamic does not provide interfaces for connecting external non-system devices 

because it is not permissible to connect ExacTrac Dynamic to such devices. 

Ensure that any external device (e.g., a USB flash drive or USB hard drive) has been removed 


To prevent unauthorized access to the Treatment Workstation, the Computer Cabinet doors are 

to be locked and the key stored in a secure location. Alternatively, it may be installed in a location 

that can be supervised at all times. It is the hospital's responsibility to ensure Computer Cabinet 

security at all times. The front interfaces and controls are not intended for user interaction during 

normal operation. 

NOTE: Do not cover the ventilation slots on the cabinet door or the back side. 

NOTE: Depending on your configuration, your system may contain a larger Computer Cabinet 

that includes an isolation transformer unit (ITU) instead of the power distribution unit (PDU). 

For further information regarding this Computer Cabinet, see the ExacTrac Dynamic Clinical 

User Guide (Version 1.1). 

Tested Cables 

The power supply line is non-detachable and not part of the ExacTrac Dynamic installation. 



Control Interface Unit (CIU) 

1 2 3 4 5 

12 11 

10 

9 

Figure 12 

8 

7 

6 

The CIU is the system control interface unit to external components, for interlock and fail-safe 

handling, and for the generator service mode. 

No. Inscription Description 

1 EXGI Varian MV Beam gating interface "EXGI" 

2 USB1 Internal USB connection 1 (EXGI protocol) 

3 CAN 1 / 2 CAN bus connections (floor box illumination) 

4 RACK PWR CIU DC power input connector 

5 

ITU 

System power remote switch interface and standby power 

supply 

6 CONSOLE ExacTrac Console connection 

7 USB 2 

Internal USB connection 2 (generator and interlock protocols) 

8 GENERATOR Dual X-ray Generator remote connection 

9 WL 1 / 2 X-ray Signal Light connection 

10 

EXT ILK 

External interlock connections to building installation 

(Door) 

11 VARIAN Varian interlock connection (EMO) 

12 ELEKTA Elekta interlock connection (Beam inhibit, EMO, Door) 

Control Interface Unit (CIU) LEDs 

1 

2 3 4 5 6 7 

Figure 13 

10 

9 

8 


System Control Unit 

The CIU also displays LEDs. 

No. Inscription Description 

1 GATING LEDs Gating function status indicator lights 

2 USB 1 LED USB bus connect indicator USB 1 

3 CAN 1 LED CAN bus traffic indicator 

4 WARNING LIGHT LEDs X-ray Signal Light status indicators 

5 

STATUS LEDs 

Differential interlock status indicators and SSG controller 

activity 

6 POWER LED CIU DC Power indicator 

7 POWER LEDs Power interlock states and standby power indicator 

8 ILK LEDs Non-differential interlock status indicators 

9 USB 2 LED USB bus connect indicator USB 2 

10 GENERATOR LEDs X-ray Generator interface status indicators 

Power Distribution Unit 

2 

1 

9 

8 

7 

6 5 4 3 

Figure 14 


1 

2 

START button 

STOP button 

• Manual system switch ON 

• Green indicator: PDU is ON 

• Manual system switch OFF 

• Red indicator: PDU STDBY power 24V DC 

3 Main circuit breaker Overload protection for PDU, main system circuit breaker 

4 Circuit breaker Overload protection for Control Room Distribution Box 

5 

6 

7 

Circuit breaker 

Circuit breaker 

AUTO-START TIMER 

Overload protection for In-Room Distribution Box (camera, 

Flat Panel Detectors and In-Room Monitor) 

Overload protection for cabinet parts (Treatment Workstation 

and KVM extenders) 

Automatic system start on workdays at a pre-defined 

time 

8 CIU POWER Blue indicator: 12V DC CIU power is ON 




9 

Start mode switch 

• CIU: System ON/OFF via ExacTrac Console (default 

configuration) 

• MANUAL: System ON/OFF via buttons 1 and 2 (for 

service only) 

NOTE: In the default configuration, the system can be started and shutdown via the ExacTrac 

Console. 




turn on the system. This means that the system can be turned off during the night (e.g., to save 

energy). 


Camera system warm up (e.g., failing the Daily Check). 

The system start time can be set according to a weekly schedule (i.e., it is possible to exclude 

weekends from the schedule). 

Example: 

Day of the Week 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Sunday 

System Startup Time 

6 a.m. 

6 a.m. 

6 a.m. 

6 a.m. 

6 a.m. 

No system start 

No system start 

For further information about the Auto-Start Timer, temperature equilibrium state B and the 

relationship to the Daily Check, see the ExacTrac Dynamic Clinical User Guide. 

NOTE: The Auto-Start Timer can be used to switch on the system only. You cannot use it to turn 

off the system. If the system is already on, the timer has no influence on the system if it triggers a 

system start at this time. 

NOTE: Depending on your configuration, the placement of the Auto-Start Timer in the large 

cabinet varies from the description here. Functionality and instructions for configuring the timer is 

identical. 


Phantoms 

2.1.5 Phantoms 

About Phantoms 

The phantoms described on the following pages are required or recommended for use with 

ExacTrac Dynamic. 

Warning 

If you have multiple ExacTrac Dynamic systems, ensure to always use the correct 

calibration phantom. 

Warning 

Accurate calibration cannot be guaranteed after deformation or damage of the system 

calibration phantoms. Handle the phantoms with care. 

Warning 

Do not move the phantom on the couch top during the calibration process. Otherwise 

subsequent patient positioning will be incorrect. 

NOTE: If the system experiences a mechanical impact to any of the thermal camera components, 

it is necessary to perform both a Daily Check and Thermal to 3D Camera Calibration. 

System Calibration Phantom 

Figure 15 

Calibrate the X-ray imaging system and 3D Camera to ensure accurate correction and verification 

of patient positioning. Use the laser marks provided to position the phantom. The phantom is also 

used for the Daily Check routine. 

The calibration phantom can be used for calibration with ExacTrac Dynamic and ExacTrac 

Dynamic Surface. For further information, see the System Calibration and Daily Check chapter in 

the ExacTrac Dynamic Clinical User Guide. 



Thermal to 3D Calibration Phantom 

Figure 16 

The ExacTrac Dynamic system uses structured light scanning and a thermal heat signature to 

reconstruct the patient's position in relation to the isocenter. The Thermal to 3D Calibration 

Phantom has circular markers that are visible to the components of the 4D Thermal Camera to 

ensure calibration of the 4D Thermal Camera to the 3D Camera. 

Verification Phantoms 

1 

2 

Figure 17 


Phantoms 


1 

2 

Pelvic Verification Phantom 

Cranial Verification Phantom 

This optional pelvis replica is used for quality assurance 

and therapist training. It is made of a tissue-like material 

inset with a bone-like material. 

For hidden target tests, one tungsten sphere is embedded 

at the approximate position of the prostate, and four 

implanted markers (copper rods) are placed around the 

tungsten sphere. 

This optional head replica is used for quality assurance 

and therapist training. It is made of a tissue-like material 

inset with a bone-like material. 

For hidden target tests, three tungsten spheres are inserted. 

NOTE: Depending on your configuration, your verification phantoms may have a different color 

(brown) without the implanted markers (copper rods) in the Pelvic Verification Phantom. 

ExacTrac Dynamic Adjustable Target Phantom 

Figure 18 

The ExacTrac Dynamic Adjustable Target Phantom can be used for Radiation Isocenter 

Calibration. It must be used together with ExacTrac Dynamic and Cranial 4Pi. 

The ExacTrac Dynamic Adjustable Target Phantom contains a tungsten sphere with a diameter 

of 5 mm which is located coincident with the crosshair of the cap. The cap is made of PEEK 

(polyether ether ketone). 

For further information about mounting the ExacTrac Dynamic Adjustable Target Phantom and 

when to use it, see the System Calibration and Daily Check chapter in the ExacTrac Dynamic 

Clinical User Guide. 



2.1.6 X-ray Components 

About X-ray Components 

ExacTrac Dynamic uses diagnostic X-rays in the kV energy range for registering the patients 

bony structure for determining the exact 3D position for treatment. 

• Two Flat Panel Detectors for stereo X-ray detection 

• Two X-ray Generators to provide energy for each X-ray tube 

• Two X-ray Tubes with collimators, covers and optional water cooling parts 

Flat Panel Detectors 

1 

Figure 19 

2 


1 

Flat Panel Detector 

• Two units: Varex model 3030DX 

• Total pixel area: 298 x 298 mm 

• Pixel resolution: 768 x 768 

• Receptor type: Amorphous silicon 

• Conversion screen: Integral columnar Csl 

The flat panels record the X-ray images generated using 

the X-ray tubes. 

2 

Device Mounts and Flat Panel 

Detector Covers 

Two Flat Panel Detectors are mounted to the ceiling, 

one on each side of the treatment couch. The device 

mounts are the carrying structure for holding each detector 

in position while acquiring the stereo images. The detachable 

covers protect the underlying structures of detector, 

holders and connecting cables. 

NOTE: Ensure that the Flat Panels are not touched by anyone or anything while the system is in 

use. Users may not affix or deposit anything onto the Flat Panels (e.g., blankets, cloth, medical 

equipment). 

NOTE: Do not hang additional objects/weights from the flat panels, cameras or ceiling mounts. 


X-ray Components 

On-Floor Covers and In-Floor Boxes and Covers 

1 

Figure 20 

2 


1 

2 

On-Floor Cover 

In-Floor Box 

Covers the X-ray tube. Two boxes with an illuminated 

area are set on top of the floor, one on either side of the 

linac. 

Contains the X-ray tube. Two boxes are recessed into 

the floor, one on either side of the linac. 

1 

2 

Figure 21 

3 


1 

2 

3 

In-Floor Box Cover 

Top cover (Elekta) 

Top cover (Varian) 

Covers the In-Floor Box and contains a light panel to illuminate 

the top cover (Elekta version shown in picture). 

Covers the In-Floor Box Cover (Elekta version shown in 

picture). 

Covers the In-Floor Box Cover (Varian version shown in 

picture). 

Do not sit on the On-Floor Cover or use it as a seat or step. 

The On-Floor Covers are installed outside of the passageway of the user/patient/personnel. 

If cracks are visible on the cover, inform Brainlab support to exchange it. 

Warning 

If water is spilled on the In-Floor Box / On-Floor Cover and/or if you suspect water leakage 

or damage of any kind, switch off the system and the X-ray Generator. Inform Brainlab 

support and do not use the system anymore. 



On-Floor Cover Placement 

6 

5 

4 

4 

3 

3 

2 

1 

2 

Figure 22 

No. 

1 

2 

3 

4 

5 

6 

Component 

Patient couch 

Medical equipment 

On-Floor Covers 

Do not place medical equipment in this area. 

Linear accelerator 

Raceway 

NOTE: Anyone entering the room during work (e.g., physicians, cleaning personnel, electricians) 

must be made aware of the room situation and the potential tripping hazards. The hospital is 

responsible for repeating this training regularly and training new personnel. 



X-ray Tubes and X-ray Collimators 

1 

2 

Figure 23 


1 

2 

X-ray Tube 

X-ray Collimator 

Water hoses 

Two Varex G892 tubes with HE221. Generates X-ray images 

for verification of patient positioning accuracy. 

When facing the linear accelerator: 

• Left tube = Tube 1 

• Right tube = Tube 2 

Ensures that the radiation emitted by the tube exclusively 

covers the sensitive area of the flat panel detector. 

Allows installation connection for cooling system. 

NOTE: It is absolutely essential to ensure that the tube is not rotating at high speed if the 

generator is turned off. An uncontrolled deceleration of the anode can cause damage to the 

bearings of the anode plate and thereby damage the tube. 

The tube runs for approximately 20 seconds on high speed after an exposure. 

If the generator is switched off while the tube is running at high speed, immediately turn the 

generator back on. The tube will automatically decelerate after switching on. 

X-ray Tube Warm-up and Seasoning 

To prevent system damage, always use the tube warm-up in the Daily Check or the dedicated 

Tube Warm-Up to warm up the X-ray tubes. 

Additional seasoning should be performed: 

• If the tubes have not been used for a longer period of time (3-4 weeks). 

• If sparking occurs. Different generator error messages can provide a hint that sparking is 

occurring, especially if the messages only appear for higher energies. With the seasoning 

procedure, it is possible to find out the highest possible energy without sparking. 

Tube seasoning should be performed in X-ray Test Acquisition mode. Tube seasoning can be 

necessary because: 

• A cold anode leads to thermal effects resulting from exposure to high power and can cause the 

anode body to crack, irreparably damaging the tube. 

• Gas and other particles may dissipate from the inner surface of the tubes into the vacuum, 

resulting in vacuum degradation. If a tube is then operated at a high voltage and current 

setting, sparking occurs. These sparks can damage the tube and the generator electronics. 



Step 

1. Take initial exposures at: 

• A minimum current setting (10 mA or less) and medium voltage (70 kV), and using 

long exposure times. 

• Low mAs (about 1 mAs) and medium voltage (70 kV). 

Irreparable damage can occur if sparking still occurs. Contact Brainlab service for further 

information. 

2. Increase the voltage in increments of 10 kV and repeat the exposures. Continue up to the 

maximum required voltage. 

NOTE: For further information, see the System Calibration and Daily Check chapter in the 

ExacTrac Dynamic Clinical User Guide. 

X-ray Tube Overheating 

In order to prevent X-ray tube overheating, ExacTrac Dynamic has implemented a mechanism 

based on the specific heating and cooling curve of the tube. If the tube becomes too hot, 

ExacTrac Dynamic does not allow any further X-ray acquisitions. The tube must cool down for a 

few minutes before further X-ray acquisition is possible. 

X-ray Generators 

Figure 24 

Component 

X-ray Generator 

Description 

Powers two X-ray tubes used to create X-ray correction 

and verification images for patient positioning. 

Provided in two separate cabinets connected with cables: 

• X-ray Generator Main (1) 

• X-ray Generator Sub (2) 

With the X-ray Generator, images can be taken nearly 

simultaneously with both tubes. 

With the generator tube combination used in ExacTrac Dynamic, a maximum tube voltage of 

150 KV can be selected, resulting in a maximum tube current of 400 mA, restricted by the 

maximum output power of the X-ray generator of 65 kW and rounded to the next lower step in the 

settings value table. 



The generator can provide all combinations of KV values and tube currents up to a KV-MA 

product of the nominal output power of 65 kW. These values are all valid for the only used 

exposure time of 100 ms with the ExacTrac Dynamic system. 

ExacTrac Dynamic provides an accuracy of X-ray tube loading factors complying with IEC 

60601-2-54: 

• Tube voltage error less than 10% 

• Tube current error less than 20% 

• Loading time error maximum 10% 

• MAS product error less than 10% 

Only qualified service personnel are allowed to install and service the following components: 

• X-ray Generator 

• HE tube unit 

• external cooling device 

Connection to hospital mains has to be done by an electrician familiar with the local regulatory 

requirements. 

NOTE: It is recommended to switch off the generator and cooling system at night. 

NOTE: Before activating X-rays, always leave the treatment room. Before acquiring X-rays, 

always verify that no one other than the patient is in the treatment room. 

The X-ray Generator and tubes are not designed for use in areas where there is a danger of 

explosion (e.g., in the presence of combustible mixtures such as anesthetics with air or oxygen, or 

in the vicinity of flammable substances such as detergents). Local regulations concerning the 

formulation of combustible gas mixtures when cleaning the system and during patient treatment 

must be observed. 

Never place objects on the X-ray Generator cabinet ventilation screen. Improper handling 

can lead to overheating and damage to the X-ray Generator. 

It is absolutely essential to ensure that the tube is not rotating at high speed if the 

generator is turned off. An uncontrolled deceleration of the anode can cause damage to the 

bearings of the anode plate and thereby damage the tube. 

The tube runs for approximately 20 seconds on high speed after an exposure. 

If the generator is switched off while the tube is running at high speed, immediately turn 

the generator back on. The tube will automatically decelerate after switching on. 

Geometrical X-ray Setup 

On-Floor installation: 

Factor 

Distance from X-ray tube focus to the flat panel 

Distance from X-ray tube focus to the isocenter 

Size of the flat panel's radiation-sensitive area 

Geometrical radiation field at the nominal reference 

distance 

Measurements 

3200 mm 

1900 mm 

300 mm x 300 mm 

178.125 mm x 178.125 mm 

In-Floor installation: 

Factor 

Distance from X-ray tube focus to the flat panel 

Distance from X-ray tube focus to the isocenter 

Measurements 

Varian Truebeam: 3500 mm 

Elekta: 3500 mm 

Varian Truebeam: 2200 mm 

Elekta: 2100 mm 



Factor 

Size of the radiation sensitive area of the flat 

panel 

Geometrical radiation field at the nominal reference 

distance 

Measurements 

300 mm x 300 mm 

Varian Truebeam: 188.57 mm x 188.57 mm 

Elekta: 180 mm x 180 mm 

Acceptable levels of extra-focal radiation are in compliance with IEC 60601-2-54. 

Permanent Filtration in the X-ray Beam 

The aluminum filtration of the system must be at least 2.5 mm. To reach this filtration, sufficient 

permanent aluminum plates must be placed within the X-ray beam path. 

NOTE: Do not remove the On-Floor Covers. 



X-ray Tube 


Additional aluminum disk (permanent filtration 

disk) 

Total Filtration 3.21 mm Al @ 75 kV 

0.71 mm Al @ 75 kV 

0.7 mm Al @ 75 kV 

0.0 mm Al 

1.0 mm Al + 0.8 mm Al 

In-Floor Box 

Top cover 

X-ray Tube 


Additional aluminum disk 

In-Floor Box cover plate 

Total Filtration 4.51 mm Al @ 75 kV 

0.98 mm Al @ 75 kV 

0.7 mm Al @ 75 kV 

0.0 mm Al 

None 

2.83 mm Al 

NOTE: The X-ray Collimator is adjusted to the size of the Flat Panel Detector. Unintended 

movement of the tube can displace the collimator and therefore the image on the Flat Panel 

Detector. The collimator must be readjusted by a service engineer and calibrated if displacement 

of the X-ray image is detected. 

If X-ray images appear eccentric and/or partial, stop treatment and contact Brainlab support. 

The patient couch induces additional filtration. Depending on the couch top that is used with 

ExacTrac Dynamic, the corresponding filtration equivalent should be taken into account. 

For further information, consult the information provided by the original manufacturer of the table 

top. 

X-ray Field Size 

The field size of the Varian G-892 X-ray tube is 430 mm x 430 mm without collimator at 1000 mm 

distance and a target angle (angle of beam) of 12°. 

The final field size with collimator depends on the installation. The maximum used area of the flat 

panel is 300 mm x 300 mm after installation. 

Calculating Dose Area Product 

As well as the image intensity, the dose area product can be calculated and shown if desired or 

legally required. To do this, additional system calibrations and measurements must be performed 

by Brainlab support. 

The dose area product is given in µGy*m² and is calculated for the image taken with the adjusted 

X-ray Generator Exposure Settings. The dose area product does not take into account the 



filtration of the couch top or other accessories in the X-ray field after the X-ray Tube, X-ray 

Collimator and In-Floor Box filtration is considered. 


performing a dose area product measurement. 

Notes 

Warning 


mechanical impact to one of its components. 

Warning 

For safety reasons, the calibration of the system needs to be verified by Daily Check at 

least once a day before patient treatment is started. 

X-ray Cooling System Components 

X-ray tube cooling is required to cool down the X-ray tube housing during treatment applications 

of intense X-ray exposure sequences. It consists of the HE221 Heat Exchanger Unit, a water/ 

water heat exchanger or water/air cooler and a Cooling System Distribution Box. The cooling 

parts are connected using hoses and quick connectors. 

Only qualified service personnel are allowed to install and service the HE tube unit and external 

cooling device. 

Brainlab recommends switching off the generator and cooling system overnight. 

Figure 25 

Component 

HE221 Heat Exchanger Unit 

Description 

• Mounted on the X-ray tube. The heat exchanger unit 

contains an oil pump that circulates the X-ray tube oil 

inside of the heat exchanger. The pump is powered via 

the X-ray Generator. 

• Provides inlet and outlet quick connectors for external 

cooling fluid. 



1 

Figure 26 

2 


1 

2 

Water/Air Cooler 

Water/Water Heat Exchanger 

Laird WL3004. Transfers the X-ray tubes' thermal load to 

the hospital chiller. 

Laird WW3001. Transfers the X-ray tubes' thermal load 

to ambient. 

Figure 27 



Component 

Cooling System Distribution Box 

Description 

• Distributes cooling fluid to both X-ray tubes at a constant 

pressure. 

• Monitors cooling liquid temperature, pressure and flow. 

X-ray Signal Light 

Figure 28 

The ExacTrac Dynamic X-ray components provide different options as X-ray signal systems: 

• Brainlab X-ray Signal Light 

• Interface for customer warning light 

If the X-ray Signal Light starts flashing while you are in the treatment room, immediately notify 

the operator at the linac control console of your presence and leave the treatment room as quickly 

as possible. 

The lights remain on until you exit the X-ray Acquisition page in the software. 

Depending on the installed version and local regulations, the X-ray signal light may have different 

colors or distinguish between steady and flashing illumination. The following description is related 

to the Brainlab X-Ray Signal Light default configuration, when the dual color signal light is used: 

State 

Steady yellow light 

Steady red light 

Flashing red light 

Description 

The X-ray Generator is switched on and may be used 

by the ExacTrac Dynamic system. The system is in 

standby mode. 

Steady red light indicates that X-ray exposures can be 

triggered with the next user interaction by pressing the 

exposure button. 

The red light will start flashing when an X-ray exposure is 

triggered, and continues to flash for at least 5 seconds 

after the last X-ray exposure. 

The X-ray Signal Light can be configured in case local regulations require different signal 

patterns. For further information, contact Brainlab support. 

For customer light installations: Different signals may be visible. 



If no door interlock is installed, the customer is responsible to ensure that no one is harmed by KV 

dose. This can either be through technical or workflow measures. 

X-ray Image QA Phantom Holder 

Figure 29 

The X-ray Image QA Phantom Holder can be used for various measurement tests, such as dose 

area product tests or image quality tests of the Flat Panel Detectors. 

Maximum weight of measuring device: 4.8 kg. 

Warning 


mechanical impact to one of its components or after performing a measurement test. 

1 

2 

3 

Figure 30 

4 




1 

2 

3 

4 

X-ray Image QA Phantom 

Holder Frame 


Holder Ball Head 


Holder Tripod 


Holder Case 

Adjustable for measurement devices with a width between 

200 and 350 mm and a thickness between 12 and 

35 mm, and a maximum weight of 4.8 kg. 

Interface between X-ray Image QA Phantom Holder 

Frame and X-ray Image QA Phantom Holder Ball 

Head. 

Maximum adjustable height: 2500 mm. 

Store and transport the X-ray Image QA Phantom Holder 

in this case. 

How to Use the X-ray Image QA Phantom Holder 

Step 

1. 

2. 

Mount the X-ray Image QA Phantom Holder Ball Head to the X-ray Image QA Phantom 

Holder Tripod. 

Assemble the X-ray Image QA Phantom Holder Frame as shown in the picture. 



Step 

3. 

Mount the measurement test device to the X-ray Image QA Phantom Holder Frame by 

using the two knobs. 

4. 

Mount the dosimeter to the front or back side of the measuring device by using the carbon 

rail and the hook-and-loop fabric. 

5. 

Mount the X-ray Image QA Phantom Holder Frame together with the measurement device 

to the X-ray Image QA Phantom Holder Tripod by inserting it into the dovetail 

guide and fastening the silver turning handle. 



Step 

6. 

Adjust the angle accordingly by loosening the silver lever. If the friction of the ball head 

needs to be readjusted due to the weight of the measuring device, see next page, How to 

Adjust the Friction of the X-ray Image QA Phantom Holder Ball Head. 

7. 

Position everything in front of and in parallel to the Flat Panel Device. 

How to Adjust the Friction of the X-ray Image QA Phantom Holder Ball Head 

If necessary, adjust the friction of the ball head with the following steps. 

1 2 3 4 

Figure 31 

Step 

1. Adjust the friction of the X-ray Image QA Phantom Holder Ball Head by adjusting the 

lever 1. 

2. Push the lever towards you 2. 



Step 

3. Hold the lever and turn it gently downwards at the same time 3. 

4. Release it. If the friction is still too weak, repeat steps 1-3 4. 


Radiation Safety 

2.1.7 Radiation Safety 

Basic Radiation Safety 

In ExacTrac Dynamic, radiological equipment is part of your system. Safe usage of this 

equipment can only be assured if: 

• The X-ray equipment is used in an appropriately shielded medical environment. 

• The system is operated by qualified personnel familiar with radiological diagnostics, X-ray 

generator operation and the radiation safety requirements for clinical radiation treatments. 

• The relevant safety instructions are observed. 

Radiation Safety Authorities 

Warning 

Serious hazards are associated with the operation of X-ray equipment. Unauthorized 

persons may not operate the X-ray equipment. The customer is responsible for ensuring 

that local regulatory requirements are followed when the equipment is installed or 

operated. The X-ray equipment should only be operated with regard to the safety 

information and additional instructions provided by the X-ray generator supplier as well as 

the competent safety authorities. 

The responsible organization shall ensure that access to ExacTrac Dynamic is restricted in 

accordance with local regulations for radiation protection. Additional information regarding 

radiation safety can also be obtained from your national radiation safety authority. 

X-ray Dosage During Patient Positioning 

The ExacTrac Dynamic X-ray components fulfill the requirements specified by IEC with regard to 

minimizing the X-ray dose to the patient during the positioning workflow. 

The typical image dose for a patient positioning is approximately 1 mGy for one pair of X-ray 

images. 

ExacTrac Dynamic has a reproducibility of radiation output of 0.05 of the Air Kerma (IEC 

60601-2-54, clause 203.6.3.2.101). 

Warning 

The user must verify each X-ray setting after modification and prior to X-ray exposure. This 

is required as in some cases the generator does not accept settings for technical reasons. 

If the settings are not accepted, the user will be notified by the software. 

Warning 

Verify that only the patient is in the treatment room before X-ray activation. 

Supported Values 

• The kV settings can be adjusted between 40 and 150 kV in steps of 10 kV. 

• The MAS-product for exposure time and tube current can be adjusted in steps between 1.3 and 

80 mAs. ExacTrac Dynamic always uses an exposure time of 100 ms and selects the tube 

current accordingly. If a selected combination of kV and mAs is not possible due to restrictions 

to the maximum tube peak power, the software will switch to the nearest possible value. 

• When adapting the X-ray Generator Exposure Settings, the generator double-checks if the 

combination of mAs and kV is possible. If not, the values are set to the closest possible 

combination. 

• ExacTrac Dynamic uses Varex X-ray tubes G-892 in B-130H housings with heat exchangers 

HE-221. The loading factors for leakage radiation for each tube are: 150 kV / 6.7 mA, limited by 

the anode with 635 kJ heat capacity. 



2.2 Other Devices 

Other Devices Compatible with ExacTrac Dynamic 

Depending on your configuration, the components listed on the following pages may be 

compatible. 

Cranial 4Pi Immobilization System 

Figure 32 

Brainlab frameless Cranial 4Pi immobilization system can be used for head and neck treatment. It 

is intended for use with ExacTrac Dynamic. 

For further information, see the Cranial 4Pi Hardware User Guide. 

Component Description Variants 

Treatment overlays 

Masks 

Fixes the mask system in place. 

Fixes the patient in place during 

treatment. 

Use with the Cranial 4Pi Headrest 

and headrest inlays. 

• Cranial 4Pi Treatment Immobilization 

Overlay Varian IGRT 


Overlay Elekta iBEAM evo 


Overlay Qfix kVue 

• Cranial 4Pi Open Face Mask 

• Cranial 4Pi Basic Mask 

• Cranial 4Pi Stereotactic Mask 

Couch Motion 

Elekta 

You can automatically position the couch and 

HexaPOD. 

Elekta linacs use the software interface MO- 

SAIQ, which allows ExacTrac Dynamic to automatically 

correct couch position. 

Varian 

You can automatically position the PerfectPitch 

couch. For automatic control of TrueBeam 

couches, no additional hardware is required. 

TrueBeam linacs use the software interface 

ADI, which allows ExacTrac Dynamic to automatically 

correct couch position. 


3 SYSTEM STARTUP AND 

SHUTDOWN 

3.1 About System Startup and Shutdown 

About This Chapter 

This chapter provides general information related to the ExacTrac Dynamic system. Which 

features are available for your system depends on your configuration, equipment and licenses. 


About Startup 

This section describes how to correctly start up the system as well as the background services. 

How to Use the Console to Start the System 

By default, use the ExacTrac Console to start the system. 

Step 

1. 

2. 

Ensure that the orange standby indicator on the console is lit. 

Press the System ON button (I) on the console. The green indicator light should turn on 

and remain lit. 

Booting Up the Treatment Workstation 

The Treatment Workstation starts up automatically after the system is powered up. Booting up 

the Treatment Workstation separately is not required. 



How to Power Up the System Via the Power Distribution Unit 

By default, use the ExacTrac Console to power up the system. System startup via the Power 

Distribution Unit (PDU) is for troubleshooting purposes only. 

Step 

1. 

2. 

In the PDU, set all circuit breakers to the ON position. 

Ensure that the red indicator of the PDU STOP button is lit (i.e., the start mode switch 

must be in the CIU position). 


About System Startup and Shutdown 

Step 

3. 

To start the system, press the START button of the PDU. Ensure that the START button's 

green indicator and the CIU POWER blue indicator are continuously lit. 




turn on the system. For further information, see the System Calibration and Daily Check chapter in 

the ExacTrac Dynamic Clinical User Guide. 

The start time must be set to at least one hour before planned clinical use. If the timer is 

programmed to start the system automatically, you can shut down the system every day after use 

(e.g., to save energy). 


Camera system warm-up (e.g., failing the Daily Check). 



3.2 Starting the ExacTrac Dynamic Software 

Background 

Once you have booted the ExacTrac Dynamic system, and accessory components such as the 

camera and Treatment Workstation are running, you can start the Preparation or Treatment 

software. 

Ensure that any external devices (e.g., a USB flash drive or USB hard drive) has been removed 


How to Start the Software 

Step 

1. To start the software, select Brainlab Elements. 

Content Manager opens. 

2. Select a workflow under ExacTrac Dynamic (e.g., Treatment). 

3. When starting Treatment, the following actions are performed. ExacTrac Dynamic system 

connects to: 

• Xray Service for configurations with X-ray capability 

• The Gating Service: Either EXGI Service for Varian linac integrations or Elekta 

Gating Service for Elekta linac integrations 

• Varian Service or Elekta Service (including iCOM Service) 

NOTE: The services start automatically during boot up of the ExacTrac Dynamic system. 


Restarting the System 

3.3 Restarting the System 

How to Restart the System 

Figure 33 

Step 

1. From the menu, select Quit Treatment App. 

2. Shut down Windows. 

3. Press System Off (O) on the console to power down ExacTrac Dynamic completely. 

4. Restart the system by selecting either: 

• System On (I) on the ExacTrac Console. 

• START on the Power Distribution Unit (System startup via the Power Distribution 

Unit is for troubleshooting purposes only.). 



3.4 Background Services 

Background Services for Software 

Figure 34 

The background services must be running before starting the ExacTrac Dynamic software. 

Services start automatically during boot up of the system. This can take up to a few minutes. 

Once the services are started properly, ExacTrac Dynamic is ready to be started. 

You can check the status of any service relevant to ExacTrac Dynamic by accessing the 

Windows Services tab of the Task Manager. 

Background Services for Integrations 

Some services that appear under the Windows Services tab of the Task Manager are relevant for 

ExacTrac Dynamic integrations. 

Varian-Relevant Services 

Xray Service 

Varian Service 

EXGI Service 

Elekta-Relevant Services 

Xray Service 

Elekta Service 

Elekta Gating Service 

iCOM Service 


Background Services 

Background Services Failure 

Figure 35 

If ExacTrac Dynamic is running when a failure occurs in the background services, a warning 

dialog is displayed. In most cases, the corresponding service auto-recovers and the dialog 

disappears. 

If it does not, you can restart the disconnected service by selecting the button to restart it. 

If the problem continues, shut down and restart the system. 

If the issue persists, contact Brainlab support. 



3.5 Shutting Down the Software 

Background 

Once patient treatment has been completed, the software can be shut down. 

If the Windows user changes, the user must close the ExacTrac Dynamic application before 

locking Windows. Otherwise, other users will be able to log in to Elements, but will not be able to 

use ExacTrac Dynamic. 

If the system is shut down before the software is closed, data can be lost. 

How to Close the Patient File 

Step 

To close the current patient file, close the patient on the linac. 

How to Exit the ExacTrac Dynamic Software 

Before shutting down the system, you must exit the ExacTrac Dynamic software correctly. 

Step 

1. Open the menu. 

2. Select Quit Treatment App. 

3. An exit prompt is shown. 

4. Select Yes to close the software. 


Shutting Down the System 

3.6 Shutting Down the System 

About Shutting Down the System 

By default, use the ExacTrac Console to shut down the system. 

For optimum system performance and reduced power consumption, Brainlab recommends 

shutting down the system every day after treatment ends (if the automatic start function is 

enabled). 

Emergency Stop/Off 

In the event of an emergency, push the emergency off switch installed in the room. 

How to Shut Down the System 

Step 

1. Shut down the Windows operating system by selecting Shut Down in the Start menu. 

2. Wait until the Treatment Workstation shuts down and the monitor goes black. 

3. 

1 

Turn off the system power by pressing the System Off button 1 on the ExacTrac Console 

for three seconds. The orange standby LED will flash during this time. 

• When the green POWER LED turns off, this indicates that system mains power is 

turned off. 

• As long as the system is OFF, the orange standby LED remains ON (indicating standby 

voltage 24 V DC). 

How to Power Down the System Via the Power Distribution System 

By default, use the ExacTrac Console to shut down the system. System shutdown via the Power 

Distribution Unit is for troubleshooting purposes only. 



Step 

1. 

2. 

Press STOP on the Power Distribution Unit. 

The green and blue indicators turn off. 

Only the red indicator remains ON (indicates 24V DC Standby power). 

Additional Notes on Shutdown 

• The circuit breakers of the Power Distribution Unit should remain always ON. Otherwise, the 

daily automatic start function cannot start up the system. 

• If you prefer to always keep the system on, the Treatment Workstation must be restarted daily 

before treatment. Otherwise, its performance may be affected. 


Overview of Available Applications 

3.7 Overview of Available Applications 

About the Applications 

• This user guide includes a description of available ExacTrac Dynamic applications. Which 

applications are available with your system depends on your configuration, equipment and 

licenses. 

• All of the applications are described in the ExacTrac Dynamic Clinical User Guide 

Preparation and Treatment Applications 

Option 

ExacTrac Dynamic Preparation 

Application 

ExacTrac Dynamic Treatment 

Application 

Description 

Select a plan (if one did not load automatically), review plan settings 

and confirm a patient plan in this application. 

Select a template with predefined treatment settings, which can be 

reviewed and adjusted to match patient-specific needs. 


Preparation Application will be referred to as Preparation. 

Perform positioning and monitoring for multiple workflows. Adjust 

settings, position the patient and monitor treatment from this application. 


Treatment Application will be referred to as Treatment. 

Quality Assurance Tools - X-ray 



Application 


Calibration 

X-ray Correction Image 

Acquisition 

Isocenter Calibration 

Radiation Isocenter Calibration 

Daily Check 


Sphere Detection 

X-ray Test Acquisition 

Tube Warm-Up 

Description 



Acquires and computes X-ray correction images. 

Calibration the surface tracking system and the X-ray system to the 

isocenter. 

Calibrates the ExacTrac Dynamic isocenter calibration to the linac 

isocenter using a metal radio-opaque sphere. 


• The cross-calibration of the 3D Camera and X-ray isocenter. 



position. 

• The tubes are warmed up. 



Calculates the distance of a metal radio-opaque sphere to the ExacTrac 

Dynamic isocenter. Measures how well the system is currently 

calibrated. 

Manually acquires X-ray images for additional quality assurance. 

Warm up the X-ray tubes. 



Quality Assurance Tools - Surface 



Application 


Calibration 




Description 



Calibrates the surface tracking system to the linac coordinate system 

and isocenter. 




position. 



Additional Tools - X-ray 

Application 


Repeat Export 

Review and Approval 


Description 



Opens completed treatment sessions for review and approval of X- 

ray/DRR image fusions. 


Additional Tools - Surface 

Application 


Repeat Export 


Description 





4 CLEANING AND 

DISINFECTION 

4.1 Cleaning Guidelines 

General Cleaning Guidelines 

The following cleaning instructions are provided for cleaning the housing, cables or other items 

not specifically listed in the following pages. 

• Ensure that the system is powered down before cleaning any parts. 

• Use non-toxic solvents only, as permitted by local regulations. Cleaning should only be 

performed in well-ventilated areas and solvents disposed of in accordance with local 

regulations. 

• Never use corrosive cleaning agents, solvents or abrasive detergents. If you are not sure about 

the properties of a cleaning agent, do not use it. 

How to Clean the Camera Covers 

Clean the device and remove dust on the air inlet on the back side of the camera unit with a 

slightly moistened cloth. Ensure that liquids do not get into the device. This can cause a short 

circuit. Do not spray the device with liquids. 

How to Clean the 3D Camera Lenses 

Step 

1. To remove dust from the camera windows, use a pressurized air duster. 

The air must be free of oil, moisture or other contaminants that could remain on the windows. 

2. To clean the window, use a small amount of isopropyl alcohol on a cleaning cloth and 

gently clean the window surface. 

Do not scratch the windows. Do not pour the alcohol directly on the windows. 

How to Clean the Thermal Camera Lens 

Step 

1. Use a commercial cleaning liquid with more than 30% isopropyl alcohol or 96% ethyl alcohol 

(C 2 H 5 OH) applied to cotton wool. 

2. Soak cotton wool in liquid, twist to remove excess liquid, clean the lens. 

Use wool once only; discard afterwards. 

Be careful when you clean the infrared lens. The lens has a delicate anti-reflective 

coating. Do not clean the infrared lens too vigorously. This can damage 

the anti-reflective coating. 


CLEANING AND DISINFECTION 

How to Clean the Flat Panel Detector Covers 

Clean the device with a slightly moistened cloth. Ensure that liquids do not get into the device. 

This can cause a short circuit. Do not spray the device with liquids. 

How to Clean the Top Covers (In-Floor Configuration) and On-Floor Covers 

Clean the cover plates or covers with a slightly moistened cloth. Ensure that liquids do not get into 

the covers. 

How to Clean the Calibration Phantoms 

Clean all phantoms using a soft and dry or slightly moistened cloth only. 

Do not touch the marker insets/marker spheres or bring them into contact with moisture. They 

contain sensitive surfaces that are required for calibration purposes. 

Ensure that liquids do not get into the Thermal to 3D Calibration Phantom. This can cause a 

short circuit. 

Do not spray the phantoms with liquids. 

Do not attempt to tamper with the System Calibration Phantom in any way (e.g., by removing or 

unscrewing the markers). 

How to Clean the Ceiling- and Wall-Mounted Monitor Arm 

For the ceiling-mounted monitor arm: 

• For all cleaning/disinfection work, disconnect pendant system from power supply system and 

protect it against accidental reconnection. Do not allow cleaning/disinfection fluid to enter the 

pendant system. 

• To avoid damage to plastic parts, do not use scouring agents and alkaline, acidic or alcoholcontaining 

cleaning agents. 

• Allow end device to cool down, if required. 

• Wipe surfaces with a slightly moistened cloth; if required, add a mild solution of soap 

(dishwashing agent). Wipe the surfaces dry with a clean cloth. 

For the wall-mounted monitor arm: 

• The mounting assembly may be cleaned with most mild, non-abrasive solutions commonly 

used in the hospital environment (e.g., diluted bleach, ammonia, or alcohol solutions). 

• The surface finish will be permanently damaged by strong chemicals and solvents such as 

acetone or trichloroethylene. 

• Do not use steel wool or other abrasive material. 

• Never submerge or allow liquids to enter the arm. Wipe any cleaning agents off of the arm 

immediately using a slightly moistened cloth. Dry the arm thoroughly after. 

How to Clean the Computer Cabinet and Distribution Boxes 

Step 

1. Switch off the Computer Cabinet and distribution boxes before starting cleaning. 

2. Clean the Computer Cabinet and distribution boxes with a slightly moistened cloth. 

Ensure that liquids do not get into the Computer Cabinet and distribution boxes. This 

can cause a short circuit. 

Do not spray the Computer Cabinet and distribution boxes with liquids. 


Cleaning Guidelines 

How to Clean the ExacTrac Console 

Step 

1. Switch off the system before starting cleaning. 

2. Clean the devices with a slightly moistened cloth. 

Ensure that liquids do not get into the devices. This can cause a short circuit. 

Do not spray the devices with liquids. 

How to Clean the X-ray Generators 

Never use abrasive cleaning agents, organic solvents or cleaning agents containing solvent. 

Step 

1. Switch off the generator before starting cleaning. 

2. Clean the generator with a slightly moistened cloth. 

Ensure that liquids do not get into the devices. This can cause a short circuit. 

Do not spray the generator with liquids. 

How to Clean the Cooling System Components 

Always switch off the cooling unit by switching off the generator before starting to clean. Never 

use abrasive cleaning agents, organic solvents or cleaning agents containing solvent. 

To clean the cooling system components (e.g., the water/water or water/air cooler and the 

Cooling System Distribution Box): 

• Clean the cooling unit and distribution box with a slightly moistened cloth. Ensure that liquids 

do not get into the devices. This can cause a short circuit. 

• Do not spray the cooling unit with liquids. 

NOTE: The cooling system uses water-propylene glycol mixture as a coolant. The coolant is not 

classified as a hazardous substance. However, if it leaks from the system, it must be disposed of 

following local regulations. 

How to Clean the In-Room Monitor 

When the liquid crystal panel becomes dusty or dirty, wipe gently with a soft cloth. 

• Do not rub the LCD panel with a hard or coarse material. 

• Do not apply pressure to the LCD surface. 

• Do not use OA cleaner as it will cause deterioration or discolor the LCD surface. 

How to Clean the Control Room Monitor, Keyboard and Mouse 

The Control Room Monitor should be cleaned using a soft dry or slightly moistened cloth only. 

Note that chemicals such as alcohol or disinfectants can cause a deterioration of the monitor 

housing and display and may lead to a reduction in image quality. 

The keyboard and mouse can be cleaned using compressed air (to blow out dust and debris from 

the keys) and a soft, dry or slightly moistened cloth with or without surface disinfectant. 

Do not spray the devices with liquids. 

How to Clean the Patient Feedback System 

Clean the device with a slightly moistened cloth. Ensure that liquids do not get behind the sleeve 

that covers the flexible arm. Do not spray the device with liquids. 


CLEANING AND DISINFECTION 

NOTE: The patient feedback system should not be used if the sleeve shows any signs of 

deterioration. 

How to Clean the Patient Feedback Glasses 

Clean the device with a slightly moistened cloth. Do not spray the device with liquids. 

How to Clean the X-ray Image QA Phantom Holder 

Clean the X-ray Image QA Phantom Holder with a slightly moistened cloth. 

Ensure that liquids do not get into the device. This can cause a short circuit. 

Do not spray the device with liquids. 


Disinfection Guidelines 

4.2 Disinfection Guidelines 

About Disinfection 

Disinfection is prescribed between patients for: 

• Patient Feedback System 

• Patient Feedback Glasses 

Perform disinfection with the tested disinfectants (below). 

NOTE: Alcohol-based cleaning and disinfection agents (e.g., Meliseptol, Mikrozid AF Liquid) are 

not suitable for the Patient Feedback Glasses. The use can influence the surface coating of the 

frame negatively. 

Disinfection is not prescribed for the following parts, but can be performed with the tested 

disinfectants (below), if desired. 

• ExacTrac Console 

• In-Floor Top Cover and On-Floor Cover 

• 4D Thermal Camera 

• Flat Panel Detector 

Tested Disinfectants 

Disinfectant Type 

Alcohol based 

Example 

Meliseptol, Mikrozid AF Liquid 

Alkylamine based Incidin Plus 2% 

Active oxygen based 

Aldehyde/chloride based 

Perform 

Antiseptica Kombi - Flächendesinfektion 

NOTE: Use only surface disinfectants released in your specific market. 

NOTE: Surface disinfectants may leave a residue. This can easily be removed using a dry cloth. 

NOTE: Use only cleaning and disinfection agents that are suitable for patient contact. 

NOTE: Brainlab evaluated the general ability of reprocessing and recommends compatible 

detergents, but the user is responsible for performing the actual disinfection in accordance with 

general regulatory requirements and the instructions of the detergent manufacturer. 

NOTE: Always closely follow the directions of the disinfectant manufacturer. Using cleaning fluids, 

disinfection wipes or cleaning procedures other than those specified may damage equipment. It is 

suggested to only use disinfectants verified by Brainlab to avoid damaging the system. 


SYSTEM MAINTENANCE 

5 SYSTEM MAINTENANCE 

5.1 System Maintenance 

Introduction 

Brainlab recommends performing recurrent maintenance tasks for ExacTrac Dynamic, as 

described in the first part of this chapter. It covers different aspects for proper operation and shall 

be executed in certain time intervals. Depending on the type of the maintenance tasks, only 

certain groups of people are authorized to perform the tasks. 

Depending on the purchased system configuration, some devices may be missing and/or related 

tests may not be applicable. 

NOTE: If you are upgrading to ExacTrac Dynamic from a previous version with older system 

parts, some tests may still be required that are described in the previous user guide. For further 

information, see the final chapter of this user guide and the corresponding ExacTrac Dynamic 

Clinical User Guide (version 1.1). 

The second part of this chapter gives guidance for handling damaged equipment and what to do 

in case the system fails in operation. 

Inspections by Brainlab Support 

• If a suitably qualified person is not available at the customer site, Brainlab support will carry out 

this inspection for a set fee. If you require a Brainlab support specialist, contact Brainlab 

support. 

• Brainlab recommends contacting Brainlab support to arrange for yearly inspections or to 

conclude a service contract. 

Inspections by Non-Brainlab Personnel 

The safety inspection must be performed by a qualified engineer: 

• Only qualified, trained and skilled personnel are allowed to perform safety inspections on 

electrical medical equipment. 

• Qualification shall include training on the subject, test equipment, knowledge, experience and 

acquaintance with the relevant technologies, standards and local regulations. 

• Personnel accessing the safety must be able to recognize possible consequences and risks 

arising from non-conforming equipment. 

Brainlab must be informed in writing immediately if equipment is deemed unsafe. 


Aspects and Types of Recurrent Inspections 

5.2 Aspects and Types of Recurrent Inspections 

Types of Maintenance Tasks 

The different maintenance tasks can be divided into general periodic maintenance inspection 

tasks (PMI) and safety technical inspection tasks (STI). The tests marked with STI are important 

and mandatory to keep the system safe and functional during its expected service life. 

The different aspects of the tasks are: 

• Visual inspections 

• Calibration checks 

• Functional tests 

• Electrical safety measurements 

Before You Begin 

• Depending on the purchased system configuration, some devices may be missing and/or 

related tests may not be applicable. 

• If you are upgrading to ExacTrac Dynamic from a previous version with older parts, some 

tests of the old system parts may still be required. For further information, see the 

corresponding ExacTrac Dynamic Clinical User Guide (Version 1.1). 

• The recurrent maintenance inspections described in this chapter do not cover regulations for 

repair actions. 



5.3 Authorized Personnel for Recurrent Inspections 

Authorized Personnel 

Two groups of people are authorized to carry out the recurrent maintenance tasks as described in 

this chapter. 

Qualified Clinical Personnel 

Brainlab Support or Brainlab-Authorized 

Support 

• ExacTrac Dynamic users who are familiar with the 

system. Knowledge and training for operating the system 

is sufficient. 

• This group shall not disassemble any part of the system. 

• Brainlab service engineers or electrically skilled technicians 

who were trained and authorized by Brainlab. 

• Extended knowledge in electrical safety and detailed 

training and authorization in certain installation tasks 

for ExacTrac Dynamic is required. 

Only Brainlab support specialists or Brainlab authorized support are permitted to perform annual 

inspections. 


Warnings and Maintenance Advice 

5.4 Warnings and Maintenance Advice 

Warnings 

Warning 

Only qualified service personnel are allowed to install and service the HE tube unit and 

external cooling device. 

Warning 

Only trained service engineers/qualified service personnel are allowed to install or service 

the distribution boxes and Computer Cabinet. Connection to hospital mains has to be done 

by an electrician familiar with the local regulatory requirements. 

Warning 

Do not service or maintain the system while patient treatment is ongoing. 

User-Serviceable Parts 

The ExacTrac Dynamic system does not contain any user-serviceable parts: No component shall 

be exchanged with non-Brainlab authorized articles. For exchange of damaged or lost parts, 

contact Brainlab service. 

Maintenance Advice 

Maintenance Advice 

Electromagnetic compatibility (EMC) 

Service contracts 

Test preconditions 

No extra test steps are required for EMC. 

If a service contract has been purchased, Brainlab will 

automatically perform the annual inspection. 

If you do not have a service contract, contact Brainlab 

support to arrange the inspection. 

Once installed, do not attempt to disconnect the Exac- 

Trac Dynamic system from the mains power supply or 

the potential equalization network. The system has no 

detachable power cord, the connection is permanent. 



5.5 Maintenance Schedule 

When to Conduct Maintenance Tests 

Interval 

Authorized Personnel 

Test Group Test Relevant Configuration 

See 

Housings, surfaces 

Visual inspection (STI) 

Connectors and cables 

Documentation 

All Page 85 

Labels and symbols 

Qualified clinical 

personnel 

Functional test 

Cooling system pressure 

Cooling system performance 

X-ray with cooling 

system 

Page 86 

Workstation clock 

All 

Accuracy check 

Image quality 

X-ray 

Page 87 

Dose area product 

X-ray with DAP* 

Emergency stop interlock 

Door contact interlock 

X-ray 


or Brainlab-authorized 

support 

Functional tests (STI) 

MV beam status interlock 

X-ray exposure redundancy 

System off interlock redundancy 

X-ray signal light 

MV beam inhibit 

All 

X-ray 

All 

X-ray 

Elekta 

Page 89 

Page 93 

Accuracy checks 

Cooling system fluid level 

PDU clock 

X-ray with cooling 

system Page 92 

All 

Electrical safety 

measurement (STI) 

PE resistance 

Touch current 

All Page 95 

* DAP: dose area product 

Interval and Authorized Personnel 

= Monthly Qualified clinical personnel 

= Annually Brainlab support or Brainlab-authorized support 

= Every two years Brainlab support or Brainlab-authorized support 

Maintenance Templates 

Templates for monthly and annual checks are available in Chapter 7, Maintenance Templates. You 

can copy them and fill them out for your records. 


Description of the Maintenance Tasks 

5.6 Description of the Maintenance Tasks 

Maintenance Tasks 

The following pages describe the specific tests to be performed. Related links to the following 

chapters are in the maintenance schedule table. 



5.6.1 Visual Inspection (STI), Monthly 

Visual Inspection 

For safety reasons, a qualitative visual inspection of the connections, wiring of all potential 

equalization conductors and parts of the system should be conducted. 

Test/Component 

Housings, surfaces 

Inspection 

• Inspect all accessible ExacTrac Dynamic 

device surfaces and search for damage. 

The test is passed if the surfaces are not 

cracked, no internal parts get accessible 

and the normal function can be maintained. 

• All parts and accessories are complete (no 

missing parts). 

• No fan outlets are blocked. 

• Control Room Monitor 

• Keyboard and mouse 

• ExacTrac Console 

• In-Room Monitor 

• Flat Panel Detector Cover 

• On-Floor Cover and In-Floor Cover 

• Camera cover 

• Computer Cabinet 

• X-ray Generator 

Connectors and cables 

• Inspect the accessible cables and connectors for correct attachment and wear. The test is 

passed if the connector is fully attached and fixed with its holdings screws. 

• Confirm the cable sheath is fully closed and has no signs of exceeded tension or drill. 

• Confirm accessible potential earth (PE) wires are correctly connected: The green-yellow PE 

wire that connects the In-Room Monitor with the ceiling-mounted monitor arm is subject to 

several bending movements. The test is passed if the wire has no sign of wear and is fixed 

on both ends. 

Documentation 

Labels and symbols 

Confirm that all accompanying system documentation 

is accessible. 

• Consult chapter 1 of this guide to identify important 

labels and symbols, such as button 

symbols on the console or device type labels 

with serial numbers. 

• Inspect the labels and markings for readability. 

• User guides 

• Generator documentation 

• Maintenance reports 

• Computer Cabinet: Type label 

• X-ray Generator: 

- Type label 

- Warning: Electricity 

• In-room distribution boxes: Warning: Electricity 

• ExacTrac Console: 

- Follow the instructions for use 

- Radioactive material or ionizing radiation 

• Control room distribution box: Warning: 

Electricity 

• X-ray Signal Light: Radioactive material or 

ionizing radiation 


Functional Test, Monthly 

5.6.2 Functional Test, Monthly 

Pressure Check and Performance Check 


Cooling System Distribution Box 

Water/Air Cooler or Water/Water 

Heat Exchanger 

Inspection 

Pressure check: 

Check that the pressure gauge of the distribution box indicates 

a correct pressure level (2-3 bar). 

Performance check: 

If there is a significant increase of pump noise in the 

cooling system, call Brainlab service for filter cleaning. 

Otherwise the cooling system may get damaged by a 

clogged pump. 



5.6.3 Accuracy Check, Monthly 

Workstation Clock 

Confirm that the time displayed on the Windows task bar (ExacTrac Dynamic Workstation 

and/or R&V workstation in the control room) is correct and synchronized. 

Image Quality 

ExacTrac Dynamic X-ray is not a diagnostic X-ray device. The image quality is not suitable for 

medical diagnosis in common clinical questions because of the needed distance between X-ray 

source and flat panels. For image-guided radiotherapy (IGRT), the image quality must be 

sufficient for an accurate positioning relative to the imaging source of the IGRT treatment 

planning. 

Prerequisites: 

• Phantom with implanted target sphere (e.g., System Calibration Phantom) and a suitable 

plan loaded on the linac. 

• A calibrated ExacTrac Dynamic system. 

To ensure a sufficient image quality for IGRT: 

Step 

1. Place the phantom on the couch with an angle and deviation to the target position. 

2. Acquire X-rays with ExacTrac Dynamic. 

3. Inspect the fusion result with Spyglass or other Fusion Verification Tools to confirm that 

the image quality is sufficient to verify the fusion result. 

4. Using the drawing tools, exclude the target sphere from the area of interest. 

5. Position the phantom with ExacTrac Dynamic. 

6. Acquire images with the linac to verify position of the target sphere. 

7. Confirm that the target sphere is positioned within 1 mm/1° of the target position. 

8. Repeat steps 1-7 with different starting positions. 

An end-to-end test from a CT to position is strongly recommended. 

The test is passed if the position of the sphere is always within 1 mm/1° of the target position. 

Dose Area Product 

Validates that the dose area produced by the system is within limits. 

NOTE: Only applicable if the dose area product functionality is installed. 

Step 

1. Measure the dose area product with an appropriate measurement device. 

2. Mount the device in the X-ray field. 

The simplest way is to mount it in front of the Flat Panel Detector. 

For the test it is sufficient to test these key values: 

Left Tube 

Right Tube 

40 kV 40 kV 

80 kV 80 kV 

140 kV 140 kV 


Accuracy Check, Monthly 

The measured dose area product for the above-mentioned exposure settings must be within 25% 

of the dose area product that ExacTrac Dynamic calculates. If the dose area product is out of 

range, Brainlab service must recalibrate the system. 



5.6.4 Functional Test (STI), Yearly 

About Interlock Tests 

1 2 3 

Figure 36 

The scope of this test includes all interlock lines of the CIU, which represent critical control signals 

for ExacTrac Dynamic operation. They are indicated with LED patterns on the STATUS 1, 

POWER 2 and ILK 3 parts of the CIU. 

The interlock tests are split into two test categories, depending on the nature of the interlock 

circuits: Functional single line and redundancy differential lines. 

Signal 

EMO OFF 

DOOR CLOSED 

MV OFF 

Inspection (Functional Single Line) 

• Within Brainlab circuits, these signals are designed so 

that any damage will lead to an assertion with safe 

blocking of the related function. The interlocks have to 

be checked on a regular basis. 

• The functional check is executed by forcing the signal 

input to the inactive state and check the correct system 

reaction and status LEDs. 

Signal 

EXP 

SYS_OFF 

Inspection (Redundancy Differential Lines) 

• These interlocks provide signal redundancy because 

two independent channels propagate the status information. 

If one of the signals fail by permanent assertion, 

the system will fall back into a safe inoperative 

state, which is detected by the user immediately. 

• If one signal is permanently active and unable to assert 

the inhibiting function, system operation remains safe 

and normal due to the redundancy of the second channel. 

• Nevertheless, in this scenario, redundancy is lost and 

must therefore be checked regularly: The redundancy 

check is performed by inspecting the related interlock 

indicator LEDs at the CIU front panel. For the test, the 

LEDs must be inspected in normal operation, inactive 

status and in a forced, invalid status by unplugging the 

related cable. 

The LEDs can show three states: 

• Off (valid inactive) 

• Red (invalid, inactive) 

• Green (valid, active) 

Depending on the test steps, certain LED colors are to be verified. 


Functional Test (STI), Yearly 

Before You Begin 

• Some tests might not apply because they depend on the system configuration. Identify which 

interlock signals are not used in the installation and mark them N/A. 

• Depending on the linac type, the linac must be online as it is a source for interlock signals. 

How to Perform the Functional Interlock Tests 

Prepare for the tests by powering up the ExacTrac Dynamic system. Enter the X-ray Test 

Acquisition page. Close the treatment door and ensure that the linac is in Beam Off status. 

Verify that X-ray exposures can be acquired with ExacTrac Dynamic. 

Verify the LED activation. Go to the Computer Cabinet, inspect the CIU front panel and inspect 

the following LEDs: 

• EMO OFF LED 

• DOOR CLOSED LED 

• MV OFF LED 

Step 

1. Emergency stop interlock. The following options must be considered: 

Varian installation: Unplug the Varian ILK connector (MC-22-a) or EXT ILK connector 

(MC-22-b) depending on the purchased configuration of the system. 

Elekta installation: Unplug the Elekta ILK connector (MC-25-b). 

• Verify that the EMO OFF LED is switched off at the CIU front panel. 

• Verify that the X-ray Generator is switched off and that the GENERATOR ON LED 

has turned off. 

2. Door contact interlock (applicable if door contact is installed). 

Open the treatment door and check that: 

• The DOOR CLOSED LED is switched off at the CIU front panel. 

• Exposures are not possible at the console. 

3. Check MV beam OFF interlock. 

Varian installation: Unplug the EXT ILK connector (MC-22-b). 

Elekta installation: No unplug is required. 

• Verify that the MV OFF LED turned on at the CIU front panel. 

• Check that the menu (upper left) on the screen is inactive on the console. 

4. Plug in all removed connectors. 

5. Check that the EMO OFF LED is on and the system interlocks DOOR CLOSED and MV 

OFF work normally again. 

Test fail criteria: 

In case of a fail, call Brainlab service for repair actions. Be aware that the system is degraded and 

may introduce a higher risk in clinical operation as it is no longer reacting on an interlock. 

How to Perform the Redundancy Interlock Tests 

Prepare for the tests by powering up the ExacTrac Dynamic system. Enter the X-ray Test 

Acquisition page. Close the treatment door and assure that the linac is in Beam Off status. Verify 

that X-ray exposures can be acquired with ExacTrac Dynamic. 

Step 

1. Check valid inactive interlock states. 

CIU front panel: Both the SYS_OFF and EXP_CON LEDs must be off. 

If the LEDs show red or green in this step, the test fails. 



Step 

2. Unplug the console cable plug MC-22-c. 

3. Check invalid interlock states. 

CIU front panel: Both the SYS_OFF and EXP_CON LEDs must be showing invalid (red). 

If the LEDs show either green or off in this step, the test fails. 

4. Plug in all removed connectors. 

5. Repeat step 1 to return system to normal operation. 

Test fail criteria: 

In case of a fail, call Brainlab service for repair actions, even though the system may work 

normally and without degradation due to the initial redundancy. Be aware that the safety 

redundancy is lost in that case. 


Accuracy Check, Yearly 

5.6.5 Accuracy Check, Yearly 

Accuracy Checks 


Cooling system heat exchanger unit 

Inspection 

Check the cooling fluid level in the reservoir. If it is 2 cm 

below maximum, perform a leakage test and add coolant 

to 1 cm below the neck top of the reservoir cap. Use only 

the cooling liquid provided by Brainlab. 

PDU clock synchronization: Power 

Distribution Unit (PDU) in the Computer 

Cabinet 

Confirm that the time displayed on the Auto-Start Timer 

in the Power Distribution Unit is correct. 

Warning 

If you notice or suspect coolant is leaking, switch off the X-ray generator. Contact Brainlab 

support and do not use the system. 

NOTE: The used cooling fluid consists of a mixture of propylene glycol (ca. 34%) and water (ca. 

66%). If there is a coolant system leak, wear gloves while cleaning up. 



5.6.6 Functional Test, Yearly 

X-ray Signal Light Test 

This test checks the function of the Brainlab X-ray Signal Light in the control room and the 

treatment room. 

Observe the warning lights and check whether they respond as intended. As you cannot be in the 

treatment room while X-rays are possible, it might be necessary to record the warning lights in the 

treatment room while you operate the ExacTrac Dynamic software. 

The customer is responsible for verifying prior to installation if the X-ray Signal Light is compliant 

with local safety regulations. The customer is also responsible for deciding whether the X-ray 

Signal Light shall be installed at their location. 

Signal light functionality tests shall be performed periodically. 

For the performance of custom warning lights, use the Indicator Light Visual Tests. 

For correct operation of the X-ray Signal Light, check that the installed light behaves according 

to this table: 

ExacTrac Dynamic Operational 

States 

Brainlab X-ray 

Signal Light – 

Yellow Lamp 

Brainlab X-ray 

Signal Light – 

Red Lamp 

External Signal 

Light Output 

Corresponding 

Console 

Status 

X-ray Generator is off Off Off Off 

ExacTrac Dynamic is 

started, X-ray Generator is 

on 

ExacTrac Dynamic waits 

for an exposure with the 

next user interaction 

ExacTrac Dynamic processes 

an X-ray exposure 

(radiation) 

Continuing five seconds after 

exposure 

On Off Off 

On Steady, red Active 

On Flashing red Active 

On Flashing red Off 

X-ray button 

is illuminated 

green 

Trefoil symbol 

is illuminated 

yellow during 

exposure 

This table represents the default configuration of the system. Different configurations are available 

for local requirements. In case of such deviations, adapt the table as defined in the customization. 

MV Beam Inhibit (Elekta Only) 

1 

Figure 37 

For this test, certain operational workflow steps have to be entered on ExacTrac Dynamic and 

the linac from the control room, while certain LEDs on the CIU in the Computer Cabinet have to 

be observed. 


Functional Test, Yearly 

A video recording device for Computer Cabinet LED observation (e.g., laptop with webcam) is 

required for this test. Set up the video recording device to record the LED on the CIU front panel 

for the GATE ILK CLOSED LED 1. 

Prepare the ExacTrac Dynamic and linac systems for operation. 

An error can be detected in the active or in the inactive status of the examined MV Beam Inhibit 

Interlock. Both states must be entered for this test. 

• Active status (LED ON): The MV Beam Inhibit signal is set with the intent that the linac MV 

beam can be activated. 

• Inactive status (LED OFF): The MV Beam Inhibit signal is cleared with the intent that the linac 

MV beam is blocked and cannot be started. 

Perform the tests as described and fill in the RESULT column of the test with PASS or FAIL. 

How to Test the MV Beam Inhibit Interlock 

Step 

1. Inactive test: Perform a patient positioning workflow for a treatment on the ExacTrac Dynamic 

system. 

Ensure that the ExacTrac Dynamic system shows an inaccurate position. 

2. Try to start the MV Beam on the linac console. 

The test passed if: 

• ExacTrac Dynamic shows the position "inaccurate" when the GATE-ILK CLOSED 

LED is off, and the linac MV Beam is inhibited. 

3. Active test: Perform a patient positioning workflow for a treatment and on the ExacTrac 


Ensure that the ExacTrac Dynamic system shows an accurate position. 

4. Try to start the MV Beam on the linac console. 

The test passed if: 

• ExacTrac Dynamic shows the position "accurate" when the GATE-ILK CLOSED LED 

is on, and the linac MV Beam can be started. 



5.6.7 Electrical Safety Measurements (STI) 

Electrical Safety Measurements 


PE resistance measurement 

Touch current measurement 

Inspection 

• Switch off the system and remove certain data cables. 

• The limit value is 0.2 Ω for the initial test and for recurrent 

tests as described below. If the electrical impedance 

between the reference point and ExacTrac Dynamic 

rises above the specified level, it must be reduced. 

• The measurement device used for initial and recurrent 

tests must be able to drive 200 mA into 500 mΩ. The 

open circuit voltage must not exceed 24 V. 

• All data and power cables must be reconnected, and 

the system must be switched on and fully operational. 

• AC measurements must be taken for every component. 

To do so, use a calibrated multimeter and a suitable 

measuring device as described in IEC 60601-1. 

The limit for all measurements is 100 μA in AC measurement 

mode. 

• Reference point for all current measurements is the 

central PE point of the treatment room as used in the 

PE resistance test. 

How to Perform a PE Resistance Test 

1 

2 

3 

Figure 38 

Step 

1. Disconnect the following data cables from the device to be tested. 

• At the workstation computer, inside the computer cabinet: 

- Disconnect flat panel sync cable 1 from COM1 port 

- Disconnect both LAN data cables for the flat panel devices 2 from the left Ethernet 

slot card (remember which cable is in top position for proper reconnection afterwards) 

• At the CIU: 

3 Remove and isolate CAN BUS cable 

2. Ensure that there is no contact between the removed cables and other device surfaces. 


Electrical Safety Measurements (STI) 

Step 

3. Measure the electrical impedance between each test point of the devices in the steps below 

and the potential equalization bar or star point ground of the treatment room. 

4. 

Note down each test point resistance measurement value. All values must be below the 

limit to pass the PE test. 

5. 

In-Room Monitor: Handle bar (part of ceiling arm structure). 

Flat Panel Detector (left and right): 

• Remove the magnetic Flat Panel Detector Cover Plate. 

• Plug the testing cable to the marked PE test socket. 



Step 

6. 

1 

X-ray Tubes (left and right): 

For On-Floor installations 1: 

• Remove the On-Floor Cover. 

• Attach the tip of the test device to a fixation screw of the collimator device on top of the 

tube. 

For In-Floor installations 2: 

• Remove the top cover sheet from the floor-boxes and remove the plate with the illumination 

element. 

• Attach the tip of the test device to the height-adjustable metal frame of the entire box. 

2 

7. 

Computer Cabinet: 

• Open the front cabinet door. 

• Attach the tip of the test device to the earthing bolt of the door. 



Step 

8. 

X-ray Generator Sub (2): 

• Open the front cover of the sub generator cabinet. 

• Attach the tip of the test device to the earthing bolt of the cover. 

How to Perform the Touch Current Test with ESA 620 Tester and Flexible Foil Pad 

Figure 39 

• The required touch current tests are from each related test point to the central PE point. 

• Use a hand-sized conductive pad to cover the test points. 

• Avoid touching the conductive part of the pad. 



Step 

1. Connect the cables from the measurement device to the measurement points using conductive 

foil such as self-adhesive copper foil or standard tin foil. 

2. 

Connect the pad via cable to the measurement device and close the circuit toward the PE 

point. 

Minimum foil size: 20 x 10 cm (8" x 4"). 

3. 

Attach the foil to the measurement surface, or wrap the foil around the component to be 

tested. The image shows the AC µA setup for the touch current measurement. 

Measure the electrical impedance of the devices in the steps below. Note the highest 

reading for your records. 

In-Room Monitor: Attach the pad to the screen surface. 



Step 

4. 

5. 

Flat Panel Detector: Remove the magnetic cover of the panel screen area and attach the 

pad to the detector surface. Avoid touching the PE grounded metal structure. 

In-Floor Box: 

1 

• In-Floor Box (Varian) 1: Remove the top cover and apply the pad to the plastic cover 

with the illumination element. Avoid touching the grounded metal frame during the 

measurement. 

• In-Floor Box (Elekta) 2: Remove the top cover and apply the 3 pad to the plastic cover 

with the illumination element. Avoid touching the grounded metal frame during the 

measurement. 

NOTE: For detailed information on completing touch current tests, consult the instruction manual 

provided with the measurement device, or refer to the relevant sections in the IEC 60601-1 

standard. 

2 



5.7 Handling Damaged Equipment 

Detected Damage 

Do not use the system or system components if: 

• The power cable or plug is damaged or frayed. 

• Liquid has been spilled into the system. 

• The system does not operate normally when the operating instructions are followed. 

• System components have been dropped or the cabinet has been damaged. 

• System components exhibit a distinct decrease in performance, indicating the need for 

servicing. 

• Liquids leak from the system. 

• Smoke is emitted by the system. 

Corrective Action 

• Switch off the system and immediately disconnect from the utility power. 

• Contact Brainlab support. 

• Attach a suitable notice such as "DO NOT USE" to the equipment to prevent it from being used 

inadvertently. 

If you continue to use equipment that has been found to be defective during an inspection, you 

risk causing injury to the patient. 

Should any power supply malfunction, only qualified personnel are permitted to perform 

troubleshooting. 

Information Available Upon Request 

Upon request, circuit diagrams, component part lists, descriptions, calibration instructions or other 

information to assist service personnel to repair ExacTrac Dynamic parts specified as repairable 

by service personnel, will be supplied by Brainlab. 


Returning Damaged Equipment 

5.8 Returning Damaged Equipment 

Reporting Damaged Equipment 

Any damaged equipment should be immediately reported to Brainlab support. 

Brainlab support will ask you for the following information: 

• Serial number of the faulty component (inscribed on the component). 

• A description of the problem. 

• Did the defect occur during the treatment? 

• Was any unintended radiation delivered to the customer? 

• Did any user or third-party injury occur? 

If the damaged happened because of a collision with the linac gantry (e.g., the couch extension 

fell to the floor), support will also need to know: 

• Was a patient on the couch when the collision happened? 

• Was a Brainlab device (e.g., ExacTrac Dynamic) controlling the movement, or if it was a 

manual movement, was the moving part a Brainlab device? 

Repair and Replacement 

The Brainlab support specialist will: 

• Provide you with cost estimate for repair or replacement. 

• Inform you when your system is expected to be operational again (usually within 48 hours). 

Removing Damaged Equipment 

Only remove defective components if instructed to do so by Brainlab support. 

Return Instructions 

• Use suitable packaging material and properly wrap and package each defective component in 

its original box, in the replacement product box, or in a suitable box so that it will not sustain 

further damage. 

• Where applicable, clean and disinfect component before returning it. Ensure that equipment is 

not activated due to neutron radiation within the treatment room (e.g., Flat Panel Detectors). 

In case of activation, contact Brainlab Support prior to sending activated equipment. 

• Complete and return the Return Material Authorization form (RMA) that was sent to you or 

accompanied the replacement part. 

• Securely tape the box shut. 

• Ship the defective product to one of the return addresses. Contact your Brainlab support 

specialist to find out where to return the product. 


COMPLIANCES AND SAFETY INFORMATION 

6 COMPLIANCES AND 

SAFETY INFORMATION 

6.1 ExacTrac Dynamic System Electronics 

Regulatory Background 

All ExacTrac Dynamic system components located in the patient vicinity fulfill safety 

requirements for electrical medical devices and systems, either as a result of individual 

component certification, or as a result of specific additional installation measures. The procedures 

in both cases are generally derived from the General Safety and Performance Requirements of 

European Regulation 2017/745, Medical Device Regulation ("MDR"), and implemented in 

accordance with the following standards and its collateral documents: 

• IEC 60601-1 [Medical electrical equipment - Part 1 General Requirements for Safety] 

Notes 

Warning 

If this equipment is modified, appropriate inspection and testing must be conducted to 

ensure continued safe use of the equipment. 

Be aware that electronic devices can be damaged by X-ray radiation. Keep ExacTrac 

Dynamic components away from the beam path. 

Safety Features 

Two main electrical safety features are implemented in the ExacTrac Dynamic system to ensure 

patient safety in accordance with IEC 60601-1: 

• An additional protective earth that provides potential equalization for the system and its 

components so that patient touch current is kept to a minimum. 

• Where required, a medical separation device ensures galvanic insulation of electrical parts in 

the patient vicinity. 

Operating and Storage Conditions 






Large temperature changes (> 5°) can cause an inaccuracy in the system. The user must perform 

calibration verification in case of large temperature changes. 


ExacTrac Dynamic System Electronics 

Do not block or cover slots on system cover or housing or other delivered equipment (e.g., 

monitor or workstation). Air must be allowed to circulate through these slots to ensure that the 

system operates properly and does not overheat. 

NOTE: If parts of the system are standing in the water or water was spilled over parts of the 

system (e.g., generator), switch off the system and the generator and inform Brainlab support. 

Warning 

Do not operate the system in damp or humid environments. Otherwise, the system may 

short circuit or be irreparably damaged. 

Warning 

Do not place system components near a heat radiator or heater register. 

Electrical Safety – ExacTrac Dynamic Classification 

ExacTrac Dynamic is classified as Class 1 medical electrical equipment according to IEC 

60601-1. 

Classification 

Class 1 

Definition 

Classification regarding protection against electric shock. 

Refers to electrical equipment in which protection against electric shock does 

not rely on basic insulation only, but which includes an additional safety precaution 

in that means are provided for accessible parts of metal or internal 

parts of metal to be protectively earthed. 

Power Specifications 

The ExacTrac Dynamic system has the following power requirements: 

• Nominal power consumption: 500 W (continuous) 

• 1.6 kVA (rated power input) 

• 100 to 240 VAC, single-phase, 50/60 Hz 

The X-ray generator has the following power requirements: 

• 35 kVA (rated power input) 

• 200 to 480 VAC, triple-phase, in steps 

• 65 kVA maximum peak power input (100 ms duration, related to exposure time) 

Procedure in the Case of Critical Malfunctions 

In the event of an electrical malfunction, follow established emergency procedure. 

Only personnel trained in fire fighting procedures should attempt to put out an electrical fire. Only 

fire extinguishers designed to put out electrical fires should be used. Do not use water under any 

circumstances. 

Warning 

In case of malfunctions, discontinue treatment immediately and contact your Brainlab 

support specialist. 

Connection Restrictions 

Do not connect miscellaneous equipment to the ExacTrac Dynamic data interfaces or the 

integrated power rail. Only equipment specified by Brainlab may be connected to the system. 

Do not connect the ExacTrac Dynamic system components directly to the mains power supply. 

To guarantee electrical safety for both the user and patient, ExacTrac Dynamic system 

components may only be powered via the integrated power rail. 



Warning 

The use of accessories and cables other than those specified (with the exception of 

transducers and cables sold by Brainlab as replacement parts) may result in increased 

emissions or decreased immunity of the equipment. 

Proper Handling of Generator Errors to Prevent Severe Damage 

Be aware that certain generator error messages (such as "KV DIFF") can hint at internal 

high voltage arcing effects during exposures. Continuous arcing can burn carbon traces 

into the surfaces, making major component changes necessary (e.g., the X-ray tubes). 

If such generator errors occur only occasionally, there is little cause for concern. If they 

occur repeatedly, avoid further such events by using other operational parameters or stop 

using the generator. Ask for Brainlab support as long as minor cleaning and re-greasing 

with silicone of insulation surfaces is sufficient. 

Do not attempt to reproduce the error. Instead, notify Brainlab support. 

Electrical Safety with the X-ray Generator 

Warning 

Even if the system is switched off, voltage is still applied to the X-ray generator in the 

power cabinet, at the power supply connections, and in the control circuits. To prevent 

serious injury or death, only trained technicians may remove the panels of the cabinet or 

exchange X-ray tubes. 

ExacTrac Dynamic Power Distribution 

In the ExacTrac Dynamic system, power is distributed by the Computer Cabinet. 

The Computer Cabinet provides the overall power for all parts of the system, such as cameras, 

monitors and X-ray flat panels. 


Electromagnetic Compatibility Information 

6.2 Electromagnetic Compatibility Information 

Background 

The following information will provide instructions about how to maintain and operate ExacTrac 

Dynamic to keep it safe and functional with regard to EMC during its expected service life. 

ExacTrac Dynamic does not contain any device which needs maintenance to ensure EMC 

compliance of the device. 

Warning 

Use of this equipment adjacent to or stacked with other equipment should be avoided 

because it could result in improper operation. If such use is necessary, this equipment and 

the other equipment should be observed to verify that they are operating normally. 

Electromagnetic Immunity 

ExacTrac Dynamic is designed and tested for reliable operation in the environment of 

radiotherapy sites. Nevertheless there is a small residual risk of electromagnetic interference 

between systems. 

ExacTrac Dynamic may show side effects like short image outages in the control room or 

flickering of control keys. Such effects do not have an influence on the ExacTrac Dynamic 

functions. The effects may be reduced by rearranging the system cable traces relative to other 

systems in the room. For further information, contact Brainlab support. 

Portable and mobile RF communications equipment can affect the systems. 

The equipment has been tested for radiated RF immunity only at selected frequencies. If emitters 

are used nearby at other frequencies, it could result in improper operation. 

Warning 

Portable RF communications equipment (including peripherals such as antenna cables and 

external antennas) should be used no closer than 30 cm (12 inches) to any part of the 

ExacTrac Dynamic system, including its cables specified by Brainlab. Otherwise, 

degradation of the performance of this equipment could result. 

ExacTrac Dynamic is intended for use in an electromagnetic environment in which radiated RF 

disturbances are controlled. 

Guidance and Manufacturer's Declaration – Electromagnetic Emissions 

Electromagnetic Emission 

Emission test 

Conducted and radiated RF emissions 

Standard 

CISPR11 

Harmonic distortion IEC 61000-3-2 

Voltage fluctuations and flicker IEC 61000-3-3 

ExacTrac Dynamic is intended for use in the following specified electromagnetic environment. 

The customer or the user of ExacTrac Dynamic should ensure that it is used in such an 

environment: 

ExacTrac Dynamic complies with RF emissions CISPR 11, Group 1, Class A: ExacTrac 

Dynamic uses RF energy for its internal function only. Therefore, its RF emissions are very low 

and are not likely to cause any interference in nearby electronic equipment. It is suitable for use in 

all establishments other than domestic and those directly connected to the public low-voltage 

power supply network that supplies buildings used for domestic purposes. Harmonic emissions 

comply with IEC 61000-3-2, Class A. Voltage fluctuations and flicker emissions comply with IEC 

61000-3-3. 



Warning 

ExacTrac Dynamic is intended for use by healthcare professionals only. The system may 

cause radio interference or may disrupt the operation of nearby equipment. It may be 

necessary to take corrective action, such as reorienting or relocating the device or 

shielding the location. 

• Reposition or relocate the affected device(s). 

• Increase the distance between the equipment and the affected device. 

• Attach the affected device to a different power source. 

• Do not operate ExacTrac Dynamic if electromagnetic interference is suspected. 

• Brainlab is not responsible for interference caused by the use of interconnected cables 

other than those recommended. 

• Contact Brainlab support for further advice. 

Electromagnetic Compatibility – Test Level Summary 

Electromagnetic Immunity, ExacTrac Dynamic System 

ExacTrac Dynamic is intended for use in professional healthcare facility environment only. The customer or the user of 

the ExacTrac Dynamic should assure that it is used in such an environment. 

The table below lists all applicable emissions tests, standards and compliance levels. 

Immunity test 

Standard 

IEC 60601-1-2 test 

level 

Compliance Level 

Guidance 

Electrostatic discharge 

(ESD) – contact 

Electrostatic discharge 

(ESD) – air 

IEC 61000-4-2 

± 8 kV 

± 15 kV 

± 8 kV 

(complies) 

± 15 kV 

(complies) 

Floors should be 

wood, concrete or ceramic 

tile. If floors are 

covered with synthetic 

material, the relative 

humidity should be at 

least 30%. 

Electrical fast transient/burst 

– input AC 

power port 

Electrical fast transient/burst 

– signal input/output 

ports 

IEC 61000-4-4 

± 2 kV 

100 kHz repetition frequency 

± 1 kV 


± 2 kV 


(complies) 

± 1 kV 


(complies) 

Mains power quality 

should be that of a 

typical commercial or 

hospital environment. 

Surge – input AC 

power port line-to-line 

Surge – input AC 

power port line-toearth 

IEC 61000-4-5 

± 1 kV 

± 2 kV 

± 1 kV 

(complies) 

± 2 kV 

(complies) 





Power frequency 

(50/60 Hz) magnetic 

field 

IEC 61000-4-8 

30 A/m 

30 A/m 

(complies) 

Power frequency 

magnetic fields should 

be at levels characteristic 

of a typical location 

in a typical commercial 

or hospital environment. 



Electromagnetic Immunity, ExacTrac Dynamic System 

Voltage dips/Voltage 

interruptions 

IEC 61000-4-11 

0% U T for 10 ms 


(0°, 45°, 90°, 135°, 

180°, 225°, 270°, 

315°) 

70% U T for 50 ms 

0% for 5 s 



(0°, 45°, 90°, 135°, 

180°, 225°, 270°, 

315°) 

70% U T for 50 ms 

0% for 5 s 

(complies) 





If the user of Exac- 

Trac Dynamic requires 

continued operation 

during power 

mains interruptions, it 

is recommended that 


be powered from an 

uninterruptible power 

supply or a battery. 

30 kHz/CW: 8 A/m, 

30 kHz/CW: n/a, 

Proximity magnetic 

fields 

IEC 61000-4-39 

134.2 kHz/PM: 

65 A/m, 

13.56 kHz/PM: 

134.2 kHz/PM: 

65 A/m, 

13.56 kHz/PM: 

-- 

7.5 A/m 

7.5 A/m 

IEC 61000-4-6, IEC 61000-4-4 

Guidance and Manufacturer’s Declaration – Electromagnetic Immunity 

ExacTrac Dynamic is intended for use in the electromagnetic environment specified below. The customer or the user 

of ExacTrac Dynamic should assure that it is used in such an environment. 

Immunity Test Standard Compliance Level Guidance 

Portable and mobile RF communications 

equipment should be used no closer to any 

part of ExacTrac Dynamic, including cables, 

than the recommended separation distance 

calculated from the equation applicable to the 

frequency of the transmitter. 

Recommended separation distance: 

Conducted disturbances 

induced by RF 

IEC 61000-4-6 

3 Vrms 

0.15 MHz to 80 MHz 

d = 1.17√P 

Radiated RF EM 

Fields 

IEC 61000-4-3 

3 V/m 

d = 1.17√P 

d = 2.3√P 

80 MHz to 800 MHz 

800 MHz to 2.5 GHz 

Proximity fields from 

RF wireless communication 

equipment – 

385 MHz 

IEC 61000-4-3 

27 V/m 

Where P is the maximum output power rating 

of the transmitter in watts (W) according to the 

transmitter manufacturer and d is the recommended 

separation distance in metres (m). 



equipment – 

450 MHz 

28 V/m 

Field strengths from fixed RF transmitters, as 

determined by an electromagnetic site survey a 

should be less than the compliance level b in 

each frequency range. 



equipment – 

710 MHz, 745 MHz, 

780 MHz 

9 V/m 

Interference may occur in the vicinity of equipment 

marked with the following symbol: 



Guidance and Manufacturer’s Declaration – Electromagnetic Immunity 



equipment – 

810 MHz, 870 MHz, 

930 MHz 



equipment – 

1720 MHz, 1845 MHz, 

1970 MHz 



equipment – 

2450 MHz 



equipment – 

5240 MHz, 5500 MHz, 

5785 MHz 

28 V/m 

28 V/m 

28 V/m 

9 V/m 

NOTE: At 80 MHz and 800 MHz, the higher frequency range applies. 

NOTE: These guidelines may not apply in all situations. Electromagnetic propagation is affected by absorption and reflection 

from structures, objects and people. 

a Field strengths from fixed transmitters, such as base stations for radio (cellular/cordless) telephones and land mobile 

radios, amateur radio, AM and FM radio broadcast and TV broadcast cannot be predicted theoretically with accuracy. 

To assess the electromagnetic environment due to fixed RF transmitters, an electromagnetic site survey should be considered. 

If the measured field strength in the location in which the ExacTrac Dynamic is used exceeds the applicable 

RF compliance level above, ExacTrac Dynamic should be observed to verify normal operation. If abnormal performance 

is observed, additional measures may be necessary, such as re-orienting or relocating ExacTrac Dynamic. 

b Over the frequency range 150 kHz to 80 MHz, field strengths should be less than [V1] V/m. 

Separation Distances 

Recommended separation distances between portable and mobile RF communications equipment and Exac- 

Trac Dynamic 

ExacTrac Dynamic is intended for use in an electromagnetic environment in which radiated RF disturbances are controlled. 

The customer or the user of the ExacTrac Dynamic can help prevent electromagnetic interference by maintaining 

a minimum distance between portable and mobile RF communications equipment (transmitters) and the ExacTrac 

Dynamic as recommended below, according to the maximum output power of the communications equipment. 

Rated maximum output 

power of transmitter 

W 

Separation distance according to frequency of transmitter m 

150 kHz to 80 MHz 

d = 1.17√P 

80 MHz to 800 MHz 

d = 1.17√P 

800 MHz to 2.5 GHz 

d = 2.3√P 

0.01 0.12 0.12 0.23 

0.1 0.38 0.38 0.73 

1 1.2 1.2 2.3 

10 3.8 3.8 7.3 

100 12 12 23 



Recommended separation distances between portable and mobile RF communications equipment and Exac- 

Trac Dynamic 

For transmitters rated at a maximum output power not listed above, the recommended separation distance d in meters 

(m) can be estimated using the equation applicable to the frequency of the transmitter, where P is the maximum output 

power rating of the transmitter in watts (W) according to the transmitter manufacturer. 

NOTE: At 80 MHz and 800 MHz, the higher frequency range applies. 

NOTE: These guidelines may not apply in all situations. Electromagnetic propagation is affected by absorption and reflection 

from structures, objects and people. 


MAINTENANCE TEMPLATES 

7 MAINTENANCE 

TEMPLATES 

7.1 Maintenance Templates 

About Maintenance Templates 

Use the templates on the following pages for documenting maintenance tests and inspections. 

Documentation of Tests 

Brainlab recommends logging all measurements for the purposes of comparison. In the event of 

significant deviations compared with previous measurements, system failure is likely to occur. In 

such cases, further detailed investigation should be completed in cooperation with Brainlab 

support. 

Record Requirements 

The test protocol must contain at least the following information: 

• Description of executing organization 

• Name of technician carrying out test 

• Serial number and exact system description (version) 

• Test description and results of tests 

• Overall evaluation 

• Date and signature 

About Upgraded Systems Using Older Components 

If your ExacTrac Dynamic 2.0 system was upgraded from an older version (ExacTrac Dynamic 

1.x), older system components may have been reused that differ from the latest hardware 

revision, such as: 

• High computer cabinet instead of the new small cabinet 

• The power supply ITU instead of the new PDU supply 

• Different KVM extenders on LAN cable-based signal transmissions instead of the new optical 

fiber cable-based 

For the periodic maintenance tests, the general components and test value limits stay the same, 

but the test procedure must be adapted to the old hardware. For example, to perform the PE 

resistance test with the older hardware, you must detach more data cables to prevent damaging 

the system during the test. 

If during testing you find deviating, older hardware components than those described parts for 

ExacTrac Dynamic 2.0, refer to the user guide of the previous system for descriptions of how to 

perform the maintenance test. 


Maintenance Task Test Protocol: Monthly, Qualified Clinical Personnel 

7.2 Maintenance Task Test Protocol: Monthly, 

Qualified Clinical Personnel 

Monthly Safety Technical Inspection Checklist 

ExacTrac Dynamic 2.0 

System Information 

System location 

• Hospital name 

• Room ID / System ID 

ExacTrac version 

ExacTrac serial number or workstation host ID 

ExacTrac system description 

Test Operator Information 

Company name 

Test operator name 

Test operator job title 

Test Protocol Information 

Test purpose 

☐ Monthly maintenance 

☐ Yearly maintenance 

☐ Repair/changes 

Bundled with other maintenance, which documents? 

Obvious incident before test? 

Test execution date 

Test Group: Visual Inspections 

Visually inspect the system parts and the accompanying documents as described in the System and Technical User 

Guide, chapter 5.6.1. Enter the results below. 

• Housings, surfaces 

• Connectors and cables 

• Documentation 

• Labels and symbols 

☐ PASS / ☐ FAIL 




Observations, reason for fail: 

Test Group: Functional and Accuracy Checks 

Conduct the following test actions as described in the System and Technical User Guide, chapter 5.6.2 and 5.6.3. Enter 

the results below. 

• PC clock synchronization 

• Image quality 

• Dose area product 

• Cooling system (between 2-3 bar) 

• Cooling system pump noise is low (no clogging) 



☐ PASS / ☐ FAIL / ☐ N/A 



Observations, reason for fail or N/A: 




Overall evaluation 

Enter the overall test result here. In case of fail: Inform the system operator and Brainlab Service. Mark the system 

accordingly. 

Overall result for this test protocol 


Reason for fail or other observations and conclusions 

Test operator name, signature and date 


Maintenance Task Test Protocol: Yearly, Brainlab Support or Brainlab-Authorized Support 

7.3 Maintenance Task Test Protocol: Yearly, Brainlab 

Support or Brainlab-Authorized Support 

Yearly Safety Technical Inspection Checklist 


System Information 

System location 

• Hospital name 

• Room ID / System ID 

ExacTrac version 

ExacTrac serial number or workstation host 

ID 

ExacTrac system description 

Test Operator Information 

Company name 

Test operator name 

Test operator job title 

Test Protocol Information 

Test purpose 

☐ Yearly maintenance 

☐ Repair/changes 

Bundled with other maintenance, which 

documents? 

Obvious incident before test? 

Test execution date 

Test Group: Monthly Maintenance Tasks 

Conduct the monthly maintenance checks and attach the related template. 

DONE: ☐ 

Test Group: Yearly functional tests (STI) 

Conduct the following test actions as described in the System and Technical User Guide, chapter 5.6.4 - 5.6.6. Enter 

the results below. 

• Emergency stop signal test 

• Door contact signal test 

• MV beam-off signal test 

• MV beam inhibit test (Elekta) 

• X-ray exposure interlock redundancy test 

• System-off interlock redundancy test 

• X-ray signal light test 








Test Group: Yearly Accuracy Checks 

Conduct the following test actions as described in the System and Technical User Guide, chapter 5.6.5. Enter the results 

below. 

• Cooling system flow interlock test 

• Cooling system accuracy. Read the water 

pressure. 


____ [bar], ☐ N/A 




• Cooling level is at least 2 cm below max, 

pressure is 2-3 bar? 

• Fill up the cooling level if required. Enter 

the amount. 

• PDU timer synchronization and setup 


____ [liter], ☐ N/A 


Test Group: Bi-Annual Electrical Safety Measurements (STI) 

Conduct the following test actions as described in the System and Technical User Guide, chapter 5.6.7. Enter the results 

below. 

PE resistance measurement (STI) 

• Measured PE resistance: In-room touch 

monitor 

• Measured PE resistance: X-ray flat panel 1 

(right) 

• Measured PE resistance: X-ray flat panel 2 

(left) 

• Measured PE resistance: X-ray tube unit 1 

(left) 

• Measured PE resistance: X-ray tube unit 2 

(right) 

• Measured PE resistance: ExacTrac computer 

cabinet 

• Measured PE resistance: X-ray sub generator 

cabinet 

PE pass confirmation: All values are below 

200 mΩ 

Enter the selected test current (min. 200 mA): _____ [mA] 

_____ [mΩ], ☐ N/A 

_____ [mΩ], ☐ N/A 

_____ [mΩ], ☐ N/A 

_____ [mΩ], ☐ N/A 

_____ [mΩ], ☐ N/A 

_____ [mΩ] 

_____ [mΩ], ☐ N/A 


Touch current measurement (STI) 

• Measured AC touch current: In-room touch 

monitor 

• Measured AC touch current: X-ray flat panel 

1 (right) 

• Measured AC touch current: X-ray flat panel 

2 (left) 

• Measured AC touch current: X-ray in-floor 

cover 1 (left) 

• Measured AC touch current: X-ray in-floor 

cover 2 (right) 

Touch current pass confirmation: All values 

are below 100 μA 

_____ [μA], ☐ N/A 

_____ [μA], ☐ N/A 

_____ [μA], ☐ N/A 

_____ [μA], ☐ N/A 

_____ [μA], ☐ N/A 


Overall evaluation 

Enter the overall test result here. In case of fail: inform the system operator and Brainlab Service. Mark the system accordingly. 

Overall result for this test protocol 


Reason for fail or other observations and 

conclusions 

Test operator name, signature and date 


INDEX 

INDEX 

A 

Al-equivalent, casings................................................................ 51 

B 

background services 

Elekta integration....................................................................67 

Varian integration....................................................................67 

backup 

protection against data loss....................................................18 

Brainlab customer service.......................................................... 27 

Brainlab service 


C 

cabinet........................................................................................38 

ExacTrac Dynamic power distribution.................................. 105 

cabling, inspection......................................................................85 

calibration 

components............................................................................ 42 

calibration phantoms.................................................................. 42 

CE label........................................................................................6 

cleaning guidelines.....................................................................74 

collimator.................................................................................... 51 

console 

ExacTrac.................................................................................31 

D 

damaged equipment.................................................................101 

detector covers...........................................................................45 

DICOM RT..................................................................................15 

disposal instructions..................................................................... 7 

dose area product...................................................................... 52 

E 

electrical equipment 

electrical safety.....................................................................103 

electrical safety 

power specifications............................................................. 104 

regulatory background..........................................................103 

safety features...................................................................... 103 

X-ray generator.....................................................................105 

electronics 

rack.........................................................................................39 

Elekta 

60601-1.................................................................................. 19 

integration...............................................................................19 

ExacTrac Dynamic components.................................................29 

ExacTrac verification phantom................................................... 43 

F 

filtration, X-ray beam.................................................................. 51 

flat panel detectors..................................................................... 45 

flat panels 

safe handling.......................................................................... 45 

floor boxes 

cleaning.................................................................................. 75 

G 

generator 

dual.........................................................................................49 

H 

handling calibration phantoms....................................................42 

hardware.................................................................................... 29 

shutdown................................................................................ 70 

X-ray components.................................................................. 45 

housing, inspection.....................................................................85 

I 

inspection guidelines.................................................................. 79 

L 

labeling, inspection.....................................................................85 

M 

monitor 

ceiling-mounted...................................................................... 33 

wall-mounted.......................................................................... 33 

O 

operating environment.........................................................11,103 

P 

pacemakers................................................................................12 

passwords.................................................................................. 25 


phantoms....................................................................................43 

isocenter calibration phantom.................................................42 

power distribution..................................................................... 105 

power specifications................................................................. 104 

protective earth.........................................................................103 

protective earth resistance......................................................... 95 

R 

rack electronics.......................................................................... 39 

radiation safety........................................................................... 60 

recovery key............................................................................... 25 

reference points..........................................................................95 

registration, evaluation and authorization of chemicals 

REACH..................................................................................... 6 

returning damaged equipment................................................. 102 

rights 


rotational angles......................................................................... 27 

S 

safe disposal................................................................................ 7 

shutdown 

hardware.................................................................................70 


INDEX 

software.................................................................................. 69 

software 

shutdown................................................................................ 69 

startup.....................................................................................65 

startup 

ExacTrac Dynamic software...................................................65 

STI..............................................................................................95 

storage conditions...................................................................... 74 

storage environment.................................................................103 

support....................................................................................... 27 

support numbers.......................................................................... 4 

sustainability..............................................................................6,7 

T 

third-party software.......................................................................5 

touch current.............................................................................. 95 

trademarks 

Brainlab.................................................................................... 5 

non-Brainlab............................................................................. 5 

treatment approval 

passwords.............................................................................. 25 

U 

user console............................................................................... 31 

shutdown................................................................................ 70 

user logs.....................................................................................25 

V 

verification 

components............................................................................ 42 

W 

warning lights............................................................................. 54 

warranty........................................................................................7 

waste electrical and electronic equipment (WEEE)......................7 

workstation................................................................................. 38 

X 

X-ray acquisition 

non-gated treatments............................................................. 60 

X-ray correction 

image acquisition....................................................................60 

X-ray equipment 

electrical safety.....................................................................105 

radiation safety....................................................................... 60 

safe handling.......................................................................... 60 

system components................................................................45 

user console........................................................................... 31 

warning system.......................................................................54 

X-ray tubes 

seasoning............................................................................... 48 

sparking.................................................................................. 48 


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Art-No. 60922-37EN 

*60922-37EN*

Exactrac Dynamic Surface CUG &amp; Dynamic STUG Combined

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Exactrac Dynamic Surface CUG & Dynamic STUG Combined