1009 - Rewiring Recovery: Anoxic Brain Injury Exacerbated Neuropsychiatric Symptoms and Functional Decline

A 24-year-old male with DiGeorge syndrome, congenital heart disease post-truncus arteriosus repair, obstructive sleep apnea, obesity, and recurrent sepsis experienced multiple MICU admissions, the latest complicated by watershed anoxic brain injury following prolonged intubation during valve replacement surgery. Previously independent in most ADLs and preparing for community college, he exhibited a profound functional and behavioral decline post-injury, including palilalia, echolalia, compulsive eating, and retrograde amnesia. He required maximal assistance for dressing, toileting, and bathing, and could no longer tolerate CPAP, AFOs, or participate in therapy. Psychiatry and brain injury rehabilitation jointly evaluated the patient to address his worsening neuropsychiatric and functional deficits.

Discussions:

Bupropion, initially trialed for executive dysfunction, worsened compulsive and perseverative behaviors and was discontinued. Psychiatry diagnosed obsessive-compulsive disorder (OCD) with symptoms predating the anoxic injury but now severely exacerbated. Sertraline was initiated at 50 mg and titrated to 250 mg, resulting in significant reductions in compulsive behaviors and improvements in memory, orientation, and ADL independence. Morning use of a 10,000-lux light box improved sleep-wake cycles and daytime alertness, which further supported re-engagement in physical therapy and use of AFOs. The patient demonstrated restored participation in self-care, reduced behavioral dysregulation, and resumed progress toward functional recovery goals.

Conclusions:

This case highlights the need for integrated psychiatric and rehabilitative care in medically complex patients with brain injury. Functional decline due to neuropsychiatric symptoms—particularly OCD—can be misattributed to cognitive impairment alone. Targeted treatment with sertraline and adjunctive light therapy led to rapid restoration of ADL performance and therapy engagement. Behavioral symptoms must be recognized as modifiable barriers to functional recovery. Close collaboration between psychiatry and rehabilitation allowed for tailored interventions that optimized outcomes. This case illustrates how early psychiatric involvement can transform trajectories in patients with overlapping neurodevelopmental, neuropsychiatric, and acquired brain injury syndromes.