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We present an algorithm for fast elastic multidimensional intensity-based image registration with a parametric model of the deformation. It is fully automatic in its default mode of operation. In the case of hard real-world problems, it is capable of accepting expert hints in the form of soft landmark constraints. Much fewer landmarks are needed and the results are far superior compared to pure landmark registration. Particular attention has been paid to the factors influencing the speed of this algorithm. The B-spline deformation model is shown to be computationally more efficient than other alternatives. The algorithm has been successfully used for several two-dimensional (2-D) and three-dimensional (3-D) registration tasks in the medical domain, involving MRI, SPECT, CT, and ultrasound image modalities. We also present experiments in a controlled environment, permitting an exact evaluation of the registration accuracy. Test deformations are generated automatically using a random hierarchical fractional wavelet-based generator.