Objective:

To appraise the cost-effectiveness, accessibility, and adoption barriers of seven intraoperative imaging modalities, including 5-ALA, fluorescein, iMRI, and iUS, in glioma surgery.

Approach:

• Comparative Cost-Effectiveness Analysis: The review evaluates the cost-effectiveness of seven imaging modalities using randomized controlled trials, systematic reviews, and health-economic analyses.
• Accessibility Assessment: The review examines barriers to accessibility, focusing on capital infrastructure and regulatory status.
• Proposed Adoption Pathway: A four-tier staged adoption pathway is proposed to guide the rational adoption of imaging technologies in resource-limited settings.

Key Findings:

• 5-ALA, iUS, and fluorescein are more cost-effective than iMRI.
• Accessibility barriers are primarily related to capital infrastructure rather than consumable costs.
• No existing cost-effectiveness analysis has adopted a low- or middle-income country payer perspective.

Interpretation:

The findings suggest a need to re-evaluate the perceived hierarchy of intraoperative imaging technologies based on resource constraints in different healthcare settings.

Limitations:

• The review focuses solely on intraoperative imaging and does not address broader resource limitations in neurosurgical practice.
• Existing literature may not fully represent low- and middle-income country contexts.

Conclusion:

A structured approach to adopting intraoperative imaging can enhance surgical outcomes in glioma treatment, particularly in resource-limited environments.