A staged adoption pathway for intraoperative imaging in brain tumor surgery: cost-effectiveness and accessibility in...

Maximal safe resection extends progression-free and overall survival in glioma surgery, and intraoperative imaging modalities are the means by which this is operationalized. Seven such modalities are now available: 5-aminolevulinic acid (5-ALA) fluorescence, fluorescein sodium, intraoperative magnetic resonance imaging (iMRI), intraoperative ultrasound (iUS), hyperspectral imaging, Raman spectroscopy and stimulated Raman histology, and augmented reality neuronavigation. Their availability is, however, profoundly unequal across high-income and resource-limited neurosurgical settings. This mini review appraises the comparative cost-effectiveness, accessibility, and adoption barriers of these seven modalities, drawing on randomized controlled trials, systematic reviews, formal health-economic analyses, and Lancet Commission data on global neurosurgical capacity. The evidence supports three arguments. That the cost-effectiveness rank order favors 5-ALA, iUS, and fluorescein over iMRI, inverting the apparent technological hierarchy. That accessibility barriers are dominated by capital infrastructure and regulatory status rather than consumable cost. And that no published cost-effectiveness analysis has yet adopted a low- or middle-income country payer perspective. A four-tier staged adoption pathway is proposed, synthesizing the Global IDEAL Sub-Framework, the NASSS framework, WHO-INTEGRATE, and Lancet Commission on Global Surgery indicators, to guide rational adoption sequences for centers operating under capital constraint.