1539 - Hallucination Related to Complete Blindness in Severe Traumatic Brian Injury: A Case of Charles Bonnet Syndrome

Case Diagnosis: Severe Traumatic Brain Injury (TBI) with polytrauma and Charles Bonnet Syndrome (CBS)

Case Description: A 28-year-old male with no prior psychiatric illness was admitted to an Inpatient Rehabilitation Facility (IRF) following a severe TBI and polytrauma sustained in a motorcycle accident. The injuries included multiple bilateral upper extremity fractures and traumatic optic neuropathy with complete vision loss. The rehabilitation period was marked by significant challenges, including severe allodynia and neuropathic pain in the left upper extremity, and hallucinations. Despite the vision loss, the patient reported vivid visual hallucinations of snakes or animals crawling. This disrupted therapeutic interventions, nursing care, caused family distress, and extended the hospital stay. Potential diagnoses considered included medication-induced hallucinations, psychosis, and seizures.

Consequently, amantadine was discontinued, and the quetiapine dose was optimized, without noticeable improvement. With no other explanatory findings, a diagnosis of CBS was concluded. The initiation of risperidone significantly reduced the frequency and intensity of hallucinations, ultimately improving the patient's engagement and participation in the rehabilitation treatment plan.

Discussions: CBS consists of recurrent visual hallucinations in visually impaired patients with preserved insight of hallucinations and the absence of other conditions better explaining the symptoms. In TBI patients in IRF, this may aggravate agitation and hinder recovery. Excluding medical causes and achieving pain control are essential as this may precipitate hallucinations. Reassurance, adequate lighting, sleep hygiene, and distraction techniques are central to management. A trial of pharmacotherapy may be justified if hallucinations are persistent, disturbing, and refractory to conservative measures. Risperidone, olanzapine, valproate, carbamazepine, and gabapentin may be trialed; however, the evidence remains limited. In the presented case, risperidone was used with a successful outcome.

Conclusions: Physiatrists should be aware of CBS as appropriate diagnosis and treatment may improve the rehabilitation course in TBI patients.