Disclosures: Anthony H. Truong: Nothing to disclose

Case Description: A 30-year-old male was referred for inpatient rehabilitation after a motor vehicle crash resulting in a severe traumatic brain injury (initial GCS-3). He was confused and combative, for which acute care psychiatry consultants prescribed 600 mg of quetiapine daily. Upon admission to the rehabilitation hospital, approximately 6 weeks post-injury, he continued to manifest confusion (Orientation log [O-log] score of 14) and agitation, with impaired balance (Berg Balance Test [BBT]13/56). The treatment team began weaning quetiapine, with progressive improvement in arousal and agitation severity. Functional Independence Measure (FIM)-ambulation subscores, however, remained at moderate assistance for 3 weeks. Further, he was still confused (O-log 18) and impulsive, with frequent falls despite 1:1 sitters. At this point, a CT head was ordered, showing marked post-traumatic hydrocephalus. A ventriculoperitoneal shunt (VPS) was then placed by Neurosurgery.

Setting: Free-standing rehabilitation hospital.

Patient: 30-year-old male with a past medical history of bipolar disorder admitted to inpatient rehabilitation after a motor vehicle accident.

Assessment/Results: After returning from VPS placement, post-traumatic confusion rapidly cleared (O-log 30/30). Improvements were also noted in walking (FIM-ambulation subscale at supervision level), and balance (BBT 54). Quetiapine was completely weaned before rehabilitation hospital discharge.

Discussion: Patients with severe TBI are at risk for multiple factors that compound TBI related cognitive impairment. This particularly includes the influence of sedating medications such as antipsychotic drugs used to treat agitation. In this case, hydrocephalus was not suspected earlier because the patient demonstrated anticipated improvement in response to weaning quetiapine. Marked improvement only occurred when significant hydrocephalus was treated.

Conclusion: Multiple confounding factors can coexist and exacerbate the cognitive impairment associated with severe TBI. Clinicians should evaluate for the presence of post-traumatic hydrocephalus in any patients with prolonged post-traumatic confusion.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/dont-wait-for-plateau-multiple-important-confounders-including-post-traumatic-hydrocephalus-hindering-functional-recovery-after-tbi-a-case-report/