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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1886-1887

Intra Cranial Hemorrhage as a Sequalae of Snakebite: A Stroke Mimicker


1 Department of Neurosurgery, AIIMS, Bhubaneswar, Odisha, India
2 Division of Neurosurgery, Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India

Date of Submission10-Sep-2020
Date of Decision10-Sep-2020
Date of Acceptance26-Mar-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Chinmaya Dash
Division of Neurosurgery, Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333453

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How to cite this article:
Dutta D, Nandan M, Dash C. Intra Cranial Hemorrhage as a Sequalae of Snakebite: A Stroke Mimicker. Neurol India 2021;69:1886-7

How to cite this URL:
Dutta D, Nandan M, Dash C. Intra Cranial Hemorrhage as a Sequalae of Snakebite: A Stroke Mimicker. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1886-7. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1886/333453




Dear Sir,

Stroke after snakebite is a rare complication.[1] Such patients present with altered sensorium or with neurological deficits, and in the absence of a clear history of snakebite, a high index of suspicion can salvage such patients.

A 62-year-old male patient presented to the emergency department of our institution with a history of altered sensorium and acute onset weakness of the left side of the body for the past six hours. The patient had no known comorbidities. No other significant history was available. The patient was a farmer by profession. Noncontrast computed tomography (CT) head revealed hemorrhage in the right parieto occipital lobe with perilesional edema and mass effect [Figure 1]a. The patient was treated as a case of stroke in a peripheral center and subsequently referred to our center. Laboratory parameters revealed a deranged coagulation profile (prolongation of prothrombin time and partial thromboplastin time along with a platelet count of 60,000/mm3) and acute kidney injury. Careful head-to-toe examination revealed bluish discoloration of the left index finger, which progressed to gangrene of the distal phalanx during the subsequent days of hospitalization [Figure 1]b. Keeping high index of suspicion, equine polyvalent anti–snake venom was transfused (20 units), and coagulation parameters were corrected with transfusion of fresh frozen plasma and platelets. The patient was taken for surgery, and decompressive craniectomy with hematoma evacuation was done [Figure 1]c. The patient improved neurologically in the postoperative period with a resolution of renal parameters and coagulopathy.
Figure 1: (a) Noncontrast computed tomography (NCCT) head axial section showing hemorrhage with perihematoma edema and mass effect. (b) Visible gangrene in the index finger. (c) Postoperative NCCT head showing evacuation of hematoma with decompressive craniectomy

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Various snake species such as Bothrops, Daboia russelii, Pseudonaja textilis, and Notechis scutatus are associated with ischemic or hemorrhagic complications of the brain.[1] Aspercitin, hemorrhagins, metalloproteinases, proteases, prothrombinase, and toxic acidic proteins are the various toxins that produce coagulopathy because of the depletion of clotting factors and fibrinogen, thereby leading to hemorrhagic complications.[2] Toxic vasculitis, complement-mediated endothelial damage and vascular spasm, massive intravascular coagulation leading to intravascular occlusion of small and large are the various mechanism that can produce ischemic stroke in patients with snakebites of these species.[3] Myoglobinuria due to myonecrosis may produce acute renal injury in such cases.[3] In patients in whom no specific history of snakebite is elicitable, laboratory parameters suggestive of consumptive coagulopathy along with relevant occupational history, especially in tropical areas, should prompt careful head-to-toe examination, which may lead the physician to a diagnosis of snakebite-associated stroke and appropriate management in such cases.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Narang SK, Paleti S, Azeez Asad MA, Samina T. Acute ischemic infarct in the middle cerebral artery territory following a Russell's viper bite. Neurol India 2009;57:479-80.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Mosquera A, Idrovo LA, Tafur A, Del Brutto OH. Stroke following Bothrops spp. snakebite. Neurology 2003;60:1577-80.  Back to cited text no. 2
    
3.
Gouda S, Pandit V, Seshadri S, Valsalan R, Vikas M. Posterior circulation ischemic stroke following Russell's viper envenomation. Ann Indian Acad Neurol 2011;14:301-3.  Back to cited text no. 3
[PUBMED]  [Full text]  


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