Digitally reconstructed radiograph (DRR) generation is an important step in several medical imaging applications such as 2D–3D image registration, where the generation of DRR is a rate-limiting step. We present a novel DRR generation technique, called the adaptive Monte Carlo volume rendering (AMCVR) algorithm. It is based on the conventional Monte Carlo volume rendering (MCVR) technique that is very efficient for rendering large medical datasets. In contrast to the MCVR, the AMCVR does not produce sample points by sampling directly in the entire volume domain. Instead, it adaptively divides the entire volume domain into sub-domains using importance separation and then performs sampling in these sub-domains. As a result, the AMCVR produces almost the same image quality as that obtained with the MCVR while only using half samples, and increases projection speed by a factor of 2. Moreover, the AMCVR is suitable for fast memory addressing, which further improves processing speed. Independent of the size of medical datasets, the AMCVR allows for achieving a frame rate of about 15 Hz on a 2.8 GHz Pentium 4 PC while generating reasonably good quality DRR.