1812 – Complex neuropsychiatric symptoms after suicidal attempt by double gunshot to the head

Cranioencephalic trauma and resulting traumatic brain injury are sometimes associated with hard to manage psychiatric symptoms, requiring interpretation from an integrated neuropsychiatric perspective. We present the case of a 49-year-old man with no known psychiatric history who attempted suicide by gunshot to the head resulting in severe cranioencephalic trauma (GCS=7) and subsequent admission to our hospital's Neurosurgery ward. Brain-CT showed two intracranial projectiles, in left temporal and right occipital topography, as well as multiple haemorragic foci. He was transferred to our Psychiatry ward, as there was no neurosurgical indication and he repeatedly attempted suicide. At admission, he presented with level of consciousness fluctuations, temporospatial disorientation, anosognosia and difficult to assess depressive symptoms. Brief neuropsychological evaluation showed deficits on visual-perceptive abilities, executive functions, logical reasoning, and immediate verbal memory, with a MoCA (Montreal Cognitive Assessment) total score under the normative values. Some language capacities (i.e. naming and repetition) were found to be preserved. Neuroophthalmological evaluation evidenced damage to the anterior left optic tract and a right campimetric defect. The EEG revealed no epileptic activity. At the 34 th day of hospitalization, after accidental choking, he began to exhibit delirium with accompanying psychotic symptoms. Presently, two-and-a-half months after admission, we observe remission of delirium, coherent and organized speech, an alexithymic pattern of response, ideative perseverance and no suicidal ideation. The noteworthiness of this case resides on the scarcity of published reports and on the difficulty it presents in terms of therapeutic and post-discharge management, originating from the hard-to-interpret symptoms and uncertain prognosis.