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S174: FROM HIGH-TECH TO LOW-COST: FLUORESCENCE-GUIDED NEUROSURGERY PATHWAYS FOR LMICS- A SYSTEMATIC REVIEW OF 560 PATIENTS
Isabel Martin del Campo¹; Xaris López Solís²; Sebastián Berumen-Arcinas²; Ignacio Pavel Navarro-Chávez¹; Ruth Yael Martínez-Hernández²; Sophie d’Herbemont¹; ¹Hospital Angeles Universidad; ²Escuela Superior de Medicina, Instituto Politécnico Nacional

Introduction: Fluorescence-guided neurosurgery (FGS) enhances visualization of tumors and vessels using indocyanine green (ICG), 5-aminolevulinic acid (5-ALA), or sodium fluorescein. Evidence shows improved aneurysm remnant detection, vessel patency, and tumor margin delineation. However, adoption in low- and middle-income countries (LMICs) is limited by the high cost of commercial platforms. Emerging near-infrared (NIR) low-cost prototypes—such as headlamp-loupe systems with generic 5-ALA, webcam/laser devices, and Raspberry Pi–based goggles—offer feasible, safe, and inexpensive alternatives, supporting wider use in skull base and neuro-oncologic surgery in resource-constrained settings.

Methods: We conducted a systematic search in PubMed, SciSpace, and Google Scholar, identifying 120 articles. Studies were eligible if they reported on feasibility, diagnostic accuracy, or surgical outcomes of NIR fluorescence in LMICs or low-cost settings. Exclusion criteria included non-fluorescence techniques, studies limited to high-income countries, and reports without outcome data. Eight studies met inclusion criteria after full-text review, encompassing 560 patients.

Results: FGS consistently improved tumor identification and excision. Sensitivity and specificity reached 93% and 100%, respectively, with gross total resection achieved in 87% of patients. Fluorescein demonstrated intraoperative fluorescence in 96% of cases. In meningiomas, resection gains occurred in 75% of high-grade and 19% of low-grade tumors. Across 58 participants, overall success was 91% (95% CI 80–97). In vascular and pituitary surgery, ICG reliably identified arteries intraoperatively, though resection rates varied among 264 reported patients. Cost reductions were substantial: fluorescein was over 100 times cheaper than 5-ALA, and hospital-prepared 5-ALA 14 times cheaper than commercial formulations. Prototype NIR devices reduced equipment costs by 8–32 times compared with microscopes.

Discussion: FGS demonstrates high sensitivity and specificity for intraoperative guidance while significantly lowering costs through generic agents and affordable imaging platforms. Innovations such as Raspberry Pi–based goggles and low-cost 5-ALA preparations achieve performance comparable to commercial systems, potentially transforming access to advanced surgical tools in LMICs. However, current evidence is limited by small sample sizes and heterogeneous methodologies. Standardized, multicenter trials are needed to validate safety, long-term outcomes, and cost-effectiveness.

Conclusion: Fluorescence-guided surgery enhances intraoperative detection and resection while significantly reducing costs through the use of generic fluorophores and low-cost imaging devices. Current evidence suggests that affordable platforms can deliver accuracy comparable to high-end systems, positioning them as scalable solutions for resource-limited settings and promising tools to advance equity and innovation in global neurosurgery.

 

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