Introduction: Deep brain stimulation (DBS) is a cornerstone treatment for medication-refractory movement disorders. Ventriculomegaly and brain atrophy, common findings in candidates for DBS, present technical challenges, prognostic dilemmas, and potential safety concerns. Their impact on clinical outcomes and procedural risk remains a subject of debate. Objective: To review the pertinent literature on the relationship between pre-operative ventriculomegaly and brain atrophy, as surrogates for subcortical and cortical neurodegeneration, and their impact on motor outcomes, safety, and surgical complications of DBS. Methods: A comprehensive literature review was performed using PubMed, Embase, and Scopus databases. Key articles addressing the prognostic and technical implications of ventriculomegaly and brain atrophy in DBS for movement disorders were selected and synthesized to provide an evidence-based perspective on the topic. Results: Multiple cohort studies demonstrate a significant correlation between larger pre-operative ventricular volumes, cortical atrophy, and subcortical volume loss with poorer motor improvement following DBS, suggesting these morphometric changes are markers of underlying neurodegenerative burden. Critically, direct evidence shows that transgressing the ventricular wall during STN DBS surgery significantly increases the risk of postoperative confusion (Relative Risk = 87). While the overall risk of severe complications like symptomatic hemorrhage remains low (approximately 1.1%), factors such as patient comorbidities, surgical technique, and postoperative electrode displacement are key contributors to adverse outcomes. Nevertheless, case reports confirm that excellent outcomes are achievable in patients with marked ventriculomegaly and brain atrophy, provided that meticulous surgical planning is employed. Conclusion: Pre-operative ventriculomegaly and brain atrophy are negative prognostic indicators for motor outcomes and direct risk factors for neurological sequelae, particularly postoperative confusion. However, they should not be absolute contraindications. With modern image-guided softwares, careful trajectory planning, and a strong clinical rationale, the risks can be mitigated and favorable outcomes achieved. Importantly, patients may derive significant quality of life benefits even with modest motor improvements. This review provides an evidence-based framework to guide clinical judgment and surgical strategy in this challenging patient population.
Díaz-Martínez et al. (Fri,) studied this question.