Acute psychogenic mutism following total hip arthroplasty under general anesthesia in an elderly patient: a case report.

Abstract

Postoperative neuropsychiatric complications most commonly manifest as delirium or cognitive impairment; however, acute isolated mutism in the absence of frank delirium or structural brain injury-referred to in some literature as acute psychogenic mutism (APM)-represents an exceedingly rare and poorly understood postoperative phenomenon. This report presents a case of APM in a 69-year-old woman following elective total hip arthroplasty under general anesthesia. The patient developed acute selective aphonia upon emergence from anesthesia, despite preserved comprehension and nonverbal communication abilities, with symptoms resolving spontaneously 44 h postoperatively. Emergent neuroimaging revealed no evidence of acute ischemic or hemorrhagic stroke, making a macro-scale cerebrovascular event unlikely.This case is notable for three distinctive features: (1) context-dependent preoperative anxiety, reflected by an Observational Anxiety Scale (OAS) score of 0 in the presence of family preoperatively, which escalated to elevated situational anxiety (HADS-A score 12, suggesting clinically relevant anxiety but not necessarily pathological) upon entry into the operating room; (2) the potential contribution of severe cerebral white matter lesions (Fazekas grade III), which may have disrupted prefrontal-limbic regulation under anesthetic stress; and (3) its occurrence in an older patient undergoing orthopedic surgery, challenging the prior association of APM predominantly with younger plastic surgery patients. We propose a tripartite etiological model integrating environmental triggers, neural vulnerability, and psychogenic dissociation, offering preliminary insights into perioperative mental health risk stratification that warrant further investigation. Non-convulsive status epilepticus was considered unlikely given the patient's alertness and interactive behavior, though EEG was not performed acutely.