Post-traumatic confusional state (PTCS) is a disabling sequel of pediatric traumatic brain injury (TBI), with little guidance on pharmacologic management when aggression and poor impulse control dominate and adherence is poor. We describe a 9-year-old boy with severe TBI who evolved from coma to a prolonged PTCS characterized by agitation, externalizing behaviors, and dysexecutive symptoms. Multiple oral agents—risperidone, methylphenidate, olanzapine, and aripiprazole—were trialed over several years with minimal benefit and poor adherence. Following an acute agitation episode in 2022, long-acting injectable (LAI) paliperidone palmitate was initiated (100 mg then 150 mg monthly) with adjunct nightly risperidone 2 mg. Over two years, aggression markedly decreased and functional status improved from Rancho Los Amigos Level IV (“confused–agitated”) to Level VIII (“purposeful–appropriate”). Cognitive testing at age 19 showed average intellectual ability but persistent executive dysfunction. Adverse effects were limited to weight gain and asymptomatic hyperprolactinemia; no extrapyramidal or cardiac events occurred. While spontaneous recovery and developmental maturation cannot be excluded, this case suggests LAI paliperidone can be a practical option to stabilize severe PTCS-related behavioral dysregulation when oral adherence fails. Larger, controlled studies are needed to clarify efficacy, safety, and long-term neurocognitive impact of LAI antipsychotics in pediatric TBI.
Ghailani et al. (Wed,) studied this question.