Transient Perioperative Aggressive Behavior during Subthalamic Nucleus Deep Brain Stimulation for Parkinson's disease

Deep brain stimulation of subthalamic nucleus (STN-DBS) is recognized as the gold standard for symptomatic treatment of advanced Parkinson's disease (PD). However, despite adherence to screening protocol, perioperative neuropsychiatric complications are increasingly being recognized. The rapid development of psychiatric symptoms within less than 24 hours is rare, and acute episodes occurring during surgery are uncommon. We present a 57-year-old female patient diagnosed with PD, with good premorbid personality. However, mild depression was detected on neuropsychological assessment. After thorough deliberation and family meeting, patient was cleared to undergo STN-DBS as the expected benefits outweighed the potential risks. Intraoperatively, during microstimulation of the left STN, patient developed sudden onset of aggressive behavior. The behavioral change lessened when the DBS lead location was adjusted to a more lateral location. The psychiatric symptoms were then controlled with quetiapine until the behavioral changes had resolved after 7 days. No recurrence was noted during follow-up consults.This case report confirms the importance of fundamental knowledge and understanding of the neuroanatomical structures affected in DBS of the STN, and their clinical implications. A thorough preoperative psychiatric evaluation is essential for comprehensive management and allows anticipation of possible adverse events.