Emergency Withdrawal Syndromes in Parkinson’s Disease Patients Treated with Subthalamic Nucleus Deep Brain Stimulation: A Narrative Review

Abstract Background Deep brain stimulation (DBS), particularly targeting the subthalamic nucleus (STN), is an advanced therapy for Parkinson's disease (PD). However, abrupt reduction of dopaminergic therapy or sudden interruption of stimulation may precipitate severe withdrawal syndromes. These include dopaminergic withdrawal syndrome (DWS), parkinsonism-hyperpyrexia syndrome (PHS)-like presentations and STN-DBS withdrawal syndrome (DBS-WS). Objective This narrative review summarizes reported cases of withdrawal syndromes in PD patients treated with STN-DBS, focusing on triggers, clinical presentation, management, and outcomes. Methods PubMed and Web of Science were searched for English-language reports published between 2007 and May 2024. Case reports and case series describing dopaminergic withdrawal, PHS-like presentations, dopamine agonist withdrawal syndrome (DAWS), or DBS-WS in PD patients treated with STN-DBS were reviewed descriptively. Results Dopaminergic withdrawal/PHS-like syndromes were mainly triggered by abrupt perioperative reduction or discontinuation of dopaminergic medications. Reported manifestations included hyperthermia, severe rigidity, autonomic instability, altered consciousness, elevated creatine kinase, seizures, renal failure, and multi-organ failure. Among six reported cases, three were fatal. DBS-WS was most commonly triggered by implantable pulse generator (IPG) depletion, hardware infection, device failure, or hardware removal. Twenty-three cases were identified. Patients typically developed rapid worsening of parkinsonism, akinesia, dysphagia, autonomic instability, hyperthermia, and systemic deterioration. Escalation of dopaminergic therapy was often insufficient, whereas IPG replacement, stimulation reactivation, or hardware reimplantation frequently led to rapid improvement. Conclusion Dopaminergic withdrawal/PHS-like syndromes and DBS-WS are rare but life-threatening emergencies in STN-DBS-treated PD patients. Early recognition, prevention of abrupt dopaminergic withdrawal, close IPG monitoring, urgent restoration of stimulation, and multidisciplinary emergency management are essential to reduce morbidity and mortality.