James H. Lau, MD
Resident, PGY-3
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, United States
Mina Gayed, DO
Assistant Professor
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, United States
A 20-year-old female with no prior history presented to outpatient clinic for management of sequelae of her brain injury due to left frontal arteriovenous malformation rupture. She experienced cognitive impairments, most notably perseveration. These perseverations, which were food-related or situational, were refractory to redirection and caused significant caregiver burden. Outbursts were frequent and impactful, causing a deterioration of the family dynamic and general wellbeing severe enough to consider institutionalization. These fixations also stymied participation with Physical, Occupational, and Speech Therapy requiring frequent breaks for re-direction. She was weaned off Methylphenidate and started on Escitalopram.
Perseveration mildly improved upon discontinuation of Methylphenidate and moderately improved upon increasing Escitalopram dosing. All therapy notes documented improvement in participation with less session breaks due to perseverations. With spasticity management and increased therapy participation, patient advanced from moderate to contact guard assistance for ambulation and transfers. Her parents reported significant improvement in their caregiver fatigue.
Discussions:
This is a case of severe perseveration post-brain injury that improved with off-label use of selective serotonin reuptake inhibitors (SSRI’s). Perseveration is commonly seen with brain injuries, but it is rarely severe to the extent where it becomes the primary driver of caregiver burden. Medication management of behavior is sometimes necessary when refractory to redirection and environmental modifications.
Conclusions:
Brain injury can cause severe perseveration that limits function and can be a significant concern. SSRI’s can be used off-label to treat this symptom.
