From high-tech to low-cost: Fluorescence-guided neurosurgery pathways for LMICs-A systematic review of 489 patients.

OBJECTIVES: To systematically review the feasibility, diagnostic accuracy, and surgical outcomes of fluorescence-guided neurosurgery (FGS) using low-cost solutions in low- and middle-income countries (LMICs). DESIGN: Systematic Review. SETTING: Neurosurgical practice in LMICs or resource-limited, low-cost settings. PARTICIPANTS: Eight studies comprising 489 patients treated with fluorescence-guided neurosurgery. Because outcomes were not uniformly reported across studies, specific endpoints were analyzed in the subsets where data were available, including an ICG vascular/pituitary cohort (n = 193) and a procedural success subset (n = 58). MAIN OUTCOME MEASURES: Feasibility, diagnostic accuracy (sensitivity and specificity), rates of gross total resection (GTR), intraoperative fluorescence detection, and cost-effectiveness of low-cost FGS platforms and generic fluorophores. RESULTS: FGS consistently improved tumor identification and excision. Reported sensitivity and specificity reached 93% and 100%, respectively, with GTR achieved in 87% of patients. Sodium fluorescein demonstrated intraoperative fluorescence in 96% of cases. In meningioma surgery, fluorescence-guided resection gains occurred in 75% of high-grade and 19% of low-grade tumors. Overall procedural success across 58 participants was 91% (95% CI 80-97). Cost reductions were substantial: fluorescein was over 100 times cheaper than commercial 5-ALA, and hospital-prepared 5-ALA was 14 times less expensive than branded formulations. Prototype NIR devices reduced equipment costs by 8-32 times compared with standard surgical microscopes. CONCLUSIONS: Fluorescence-guided neurosurgery enhances intraoperative detection and resection while substantially lowering costs through generic fluorophores and affordable imaging platforms. These low-cost FGS solutions represent scalable tools for resource-limited settings and have strong potential to advance equity and innovation in global neurosurgery.