The Recall Desk
HighFDA (Devices)·Z-1205-2019·Announced 2019-05-01

Brainlab RT Elements Software Recalled for Incorrect Dose Calculation

Brainlab AG is recalling specific versions of RT Elements software due to a potential for incorrect dose distribution calculations when using the Pencil Beam algorithm on the GPU.

What this means for you

Real risk of harm even if no illness or injury has been reported yet. Stop using the product and follow the agency's guidance.

Our severity reasoning: The recall involves a medical device software defect that could lead to incorrect radiation dose calculations, posing a risk of harm to patients, although no specific injuries or illnesses are reported in the source text.

Plain-English summary

Brainlab AG is recalling specific versions of its RT Elements software applications, including Cranial SRS, Spine SRS, Multiple Brain Mets SRS, and RT QA. The affected software versions are 1.0.0 and 1.5.0 for Cranial SRS, Spine SRS, and RT QA, and version 1.5.0 for Multiple Brain Mets SRS.

The recall is issued because there is a potential for an incorrect dose distribution calculation under specific circumstances. This issue occurs when using the Pencil Beam algorithm on the GPU (graphics card), which is the default system setting for these applications. The software is used for radiation treatment planning for stereotactic, conformal, and computer-planned Linac-based radiation treatment of cranial, head and neck, and extracranial lesions.

The recall affects 164 units in the United States and 333 units outside the US. Distribution was worldwide, including nationwide distribution in the US across multiple states and various international locations. Users of the affected software should contact Brainlab AG for further instructions on corrective actions.

The recalled product

Product
RT Elements Software revisions of the RT Elements applications have a specific software version number. Specifically the following RT Elements applications/versions are affected: - Cranial SRS 1.0.0 and 1.5.0 - Spine SRS 1.0.0 and 1.5.0 - Multiple Brain Mets SRS 1.5.0 -
Manufacturer
Brainlab AG

Distribution

Distributed nationwide across the United States.

The notice also names 28 states specifically: