PurposeNoninvasive frameless systems are increasingly being utilized for head immobilization in stereotactic radiosurgery (SRS). Knowing the head positioning reproducibility of frameless systems and their respective ability to limit intrafractional head motion is important in order to safely perform SRS. The purpose of this study was to evaluate and compare the intrafractional head motion of an invasive frame and a series of frameless systems for single fraction SRS and fractionated/hypofractionated stereotactic radiotherapy (FSRT/HFâSRT).MethodsThe noninvasive PinPoint system was used on 15 HFâSRT and 21 SRS patients. Intrafractional motion for these patients was compared to 15 SRS patients immobilized with CosmanâRobertsâWells (CRW) frame, and a FSRT population that respectively included 23, 32, and 15 patients immobilized using GillâThomasâCosman (GTC) frame, Uniframe, and Orfit. All HFâSRT and FSRT patients were treated using intensityâmodulated radiation therapy on a linear accelerator equipped with coneâbeam CT (CBCT) and a robotic couch. SRS patients were treated using gantryâmounted stereotactic cones. The CBCT imageâguidance protocol included initial setup, pretreatment and postâtreatment verification images. The residual error determined from the postâtreatment CBCT was used as a surrogate for intrafractional head motion during treatment.ResultsThe mean intrafractional motion over all fractions with PinPoint was 0.62 ± 0.33 mm and 0.45 ± 0.33 mm, respectively, for the HFâSRT and SRS cohort of patients (Pâvalue = 0.266). For CRW, GTC, Orfit, and Uniframe, the mean intrafractional motions were 0.30 ± 0.21 mm, 0.54 ± 0.76 mm, 0.73 ± 0.49 mm, and 0.76 ± 0.51 mm, respectively. For CRW, PinPoint, GTC, Orfit, and Uniframe, intrafractional motion exceeded 1.5 mm in 0%, 0%, 5%, 6%, and 8% of all fractions treated, respectively.ConclusionsThe noninvasive PinPoint system and the invasive CRW frame stringently limit cranial intrafractional motion, while the latter provides superior immobilization. Based on the results of this study, our clinical practice for malignant tumors has evolved to apply an invasive CRW frame only for metastases in eloquent locations to minimize normal tissue exposure.