Volume 2 - Issue 12

Ischemic stroke after Russel's Viper snake bite, an infrequent event: a case report

S. Yogeshwaran1,*, P. Saravana Kumar2, C.M. Santhosham3, P. Sasikumar4

1 MEM-Post Graduate, Kauvery Hospital, Cantonment-Trichy, Tamilnadu, India

2HOD Critical Care, Kauvery Hospital, Cantonment-Trichy, Tamilnadu, India

3Critical Care Specialist, Kauvery Hospital, Cantonment-Trichy, Tamilnadu, India

4Anaesthesiologist, Kauvery Hospital, Cantonment-Trichy, Tamilnadu, India

*Correspondence: dryogeshmbbs@gmail.com 

 

Abstract

Snake bites are a well-known medical emergency in many parts of the world including India. This results in tens of thousands of deaths every year and many chronic disabilities in South Asian countries. Though much is now known about the species of venomous snake, the nature of their bites and clinical effects of envenomation, cerebral arterial thrombosis following snake bite has been sparsely described in the literature. We describe a case of acute multiple cerebral infarction following Russel viper bite and envenomation.

 

Background

Many snake bites patients are treated by traditional healers in South Asian regions and thus the epidemiology of snake bites has not been adequately studied. According to WHO Direct estimate, India measures highest number of cases of snake bite worldwide, with a mortality estimated 46,000 annual death [1]. A new study has found an estimated 1.2 million people died from snake bites India in the past two decades, averaging 58,000 deaths every year, with nearly half of the victims aged 30 to 69 years, and over a quarter being children under 15 years. Snake bite envenomation is a neglected but important public health problem in rural areas of South Asia, South east Asia and Sub Saharan Africa [2]. The big four medically significant species in India are naja naja, Bungarus carefues, Debois russelli and Echis carinatus. Viper being the most common cause of bite, local envenomation is the frequent manifestation, followed by haemostatic abnormalities and neurotoxicity [3]. Coagulopathy if present is diagnostic of viper bites in South Asia. Viper bites have been associated rarely with cerebrovascular complications, most commonly due to haemorrhages, and rarely due to infarct. Ischemic stroke following viper bite is quite rare [4]. 

Most common and serious central nervous system complication following snake bite is intracranial haemorhage [5]. Ischemic stroke, when present, commonly involves anterior circulation. Here we describe a polyvalent anti venom treated patient with multiple infarcts in the Right temporo-parietal and left fronto-parietal region and cerebellar cortex, with mass effect.

Case Presentation

A 42-years-old female with no co-morbidities was admitted to our ER with alleged history of snake bite on her left hand. The snake was killed and brought by the relatives in a cover to ER and it was identified as Russell's viper (Fig. 1), within 10 minutes after bite, she noticed mild swelling over the bite area and was brought to ER within an hour in an unresponsive and gasping state. She was immediately intubated and put on mechanical ventilation, her whole blood clotting time was more than 20 min and ASV 10 vials was administered subsequently she received 20 more vial. Her initial labs showed leukocytosis, thrombocytopenia, elevated international normalised ratio, prothrombin time and activated prothrombin time. Kidney function was normal. CT brain was normal.

Russell's viper from the wild

Fig. 1. Russell's viper from the wild

 

Patient sensorium did not improve in the first 48 h, on the third day withdrawal to pain, on left side was appreciated, MRI Brain was done in view of Right-side paucity, which showed - acute infarct in Right Tempero - Parietal and Left Fronto Parietal region and Right Cerebellar Cortex, with mass effect.

She was managed on mechanical ventilator, antibiotics and supportive care, tracheostomy was done in view of long-term ventilation and was weaned off accordingly. On 35th day of admission, she was discharged with a GCS-E4VTM5 with right side paucity.

On Examination

HB

10.3

PCV

32.1

Platelets

1,24,000

Total Leucocyte Count

18,000

PT

>2 min

INR

10

APTT

>2 min

Sr Urea

30.6

Sr Creatinine

0.65

Sr Na

145

Sr K

2.99

Sr Chloride

111

Sr HCo3

19.0

 

MRI - Brain

MRI Brain - Acute infarct in Right Tempero- Parietal and Left Fronto Parietal region and Right Cerebellar Cortex, with mass effect


MRI Brain

MRI Brain

MRI Brain

Discussion

Viper bite is the most frequent snake bite in the Indian subcontinent. Envenomation by viper bite leads to local manifestations, followed   by abnormal coagulation [6]. The various toxins present in the viper venom can be categorized both as pro-coagulant and anticoagulant. The toxins with well-established pro-coagulant/platelet aggregating properties are cerastobin [6], factor IVA [7], cerastocytin [8], cerastotin [9], and afaacytin [10].

These various protein products have thrombin like enzymatic activity. Different toxins activate different parts of the coagulation cascade [6-10]. Their activity is inhibited by monoclonal antibodies against GP1b or GPIIb/IIIa or thrombin receptor. Disseminated intravascular coagulation and hypotension are also associated risk factors in viper bite patients. Disseminated intravascular coagulation can be a cause   of neurological deficits, largely due to vessel occlusion [11]. The toxin itself can cause vasospasm which can lead to a cerebrovascular catastrophe. Reported case reports of infarct following snake bite are mostly due to viper bite. Most of the patients had features of local envenomation with disseminated intravascular coagulation. The infarct commonly involved the anterior circulation, with hemiparesis being the frequent presentation [12-15]. As a matter of fact, cerebral infarction after snake envenomation occurs due to a complex multifactorial mechanism. It includes direct cardiotoxic effects of venom leading to dysrrhythmias. This may cause cardiac thromboembolism. Hyperviscosity due to hypovolemia and hypoperfusion secondary to hypotension may also be a contributing factor to causation of ischemic strokes [16-18].

Conclusion

After viper bite, neurological manifestations can be attributed to various reasons, such as toxin induced vasculitis, procoagulant effect, endothelial damage, disseminated intravascular coagulation and hypotension. In a snake bite prone country like India, it is necessary to evaluate the incidence of ischemic stroke and other neurological disorders from possible viper bite. The early detection of the viper bite and administration of anti-snake venom can prevent this infrequent but devastating complication.

References

  1. WHO. Working to overcome the global impact of neglected tropical diseases. 2010. Retrieved from who.int/ neglected diseases/2010 report
  2. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: a literature analysis and modeling based on regional estimates of envenoming and deaths. PLoS Med. 2008:5(11):e218.
  3. Snakebite Mortality in India: A Nationally Representative Mortality Survey published in PLoS in 2011 and based on the Indian Million Death Study estimated 46,000 annual deaths caused by snakebite in India.
  4. Alirol E, Sharma SK, Bawaskar HS, et al. Snake bite in South Asia: a review. PLoS Negl Trop Dis. 2010;4:Art.630.
  5. Mohapatra B, Warrell DA, Suraweera W, et al. Million death study collaborators. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis. 2011;5:Art.1018.
  6. Inamdar IF, Aswar NR, Ubaidulla M, et al. Snakebite: Admissions at atertiary health care in Maharashtra, India. S Afr Med J. 2010;100:456-8.
  7. Kulkarni ML, Anees S. Snake venom poisoning: Experience with 633 cases. Indian Pediatr. 1994;31:1239-43.
  8. Mosquera A, Idrovo LA, Tafur A, et al. Stroke following Bothrops spp. Snake bite. Neurology 2003;60:1577-80.
  9. Farid TM, Tu AT, el-Asmar MF. Effect of cerastobin, a thrombinlike enzyme from Cerastes viper (Egyptian sand snake) venom, on human platelets. Haemostasis 1990;20:296-304.
  10. Basheer AR, el-Asmar MF, Soslau G. Characterization of a potent platelet aggregation inducer from Cerastescerastes (Egyptian sand viper) venom. Biochim Biophys Acta. 995;1250:97-109.
  11. Dekhil H, Wasner A, Marrakchi N, et al. Molecular cloning and expression of a functional snake venom serine proteinase, with platelet aggregating activity, from Cerastes viper. Biochemistry 2003;42:10609-18.
  12. Marrakchi N, Barbouche R, Guermazi S, et al. A serine protease from Cerastescerastes venom, with plateletaggregating and agglutinating properties. Eur J Biochem. 1997;247:121-8.
  13. Laraba-Dejabri F, Martin-Eauclaire MF, Mauco G, Marchot P. Afaacytin,an alpha beta- Fibrinogenase from erastescerastes (horned viper) venom, activates purified factor X and induces serotonin release from human blood platelets. Eur J Biochem. 1995;233:756-65.
  14. Scwartzmann RJ, Hill JB. Neurological complications of disseminated intravascular coagulation. Neurology 1982;32:791-7.
  15. Rebahi H, Nejmi H, Abouelhassan T, et al. Severe envenomation by Cerastescerastes viper: An unusual mechanism of acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014;23:169-72.
  16. Pal J, Mondal S, Sinha D, et al. Cerebral infarction: An unusual manifestation of viper snake bite. Int J Med Sci. 2014;2:1180-3.
  17. Paul G, Paul BS, Puri S. Snake bite and stroke: Our experience of two cases. Indian J Crit Care Med. 2014;18:257-8.
  18. Narang SK, Paleti S, Azeez Asad MA, et al. Acute ischemic infarct in the middle cerebral artery territory following a Russells viper bite. Neurol India. 2009;57:479-80. 

Dr. S. Yogeshwaran

Dr. S. Yogeshwaran

MEM Postgraduate


Dr. P. Saravana Kumar

Dr. P. Saravana Kumar

HOD Critical Care


Dr. C. M. Sathosam

Dr. C. M. Sathosam

Critical Care Specialist


Dr. P. Sasi Kumar

Dr. P. Sasi Kumar

Anaesthesiologist


Kauverian - Scientific Journals - Volume 1 - issue 1


Kauverian - Scientific Journals - Volume 1 - issue 2


Kauverian - Scientific Journals - Volume 1 - issue 3


Kauverian - Scientific Journals - Volume 1 - issue 4


Kauverian - Scientific Journals - Volume 1 - issue 5


Kauverian - Scientific Journals - Volume 1 - issue 6


Kauverian - Scientific Journals - Volume 1 - issue 7


Kauverian - Scientific Journals - Volume 1 - issue 8


Kauverian - Scientific Journals - Volume 1 - issue 9


Kauverian - Scientific Journals - Volume 2 - issue 1


Kauverian - Scientific Journals - Volume 2 - issue 2


Kauverian - Scientific Journals - Volume 2 - Issue 3


Kauverian - Scientific Journals - Volume 2 - Issue 4


Kauverian - Scientific Journals - Volume 2 - Issue 5


Kauverian - Scientific Journals - Volume 2 - Issue 6


Kauverian - Scientific Journals - Volume 2 - Issue 7


Kauverian - Scientific Journals - Volume 2 - Issue 8


Kauverian - Scientific Journals - Volume 2 - Issue 9


Kauverian - Scientific Journals - Volume 2 - Issue 10


Kauverian - Scientific Journals - Volume 2 - Issue 11


Kauverian - Scientific Journals - Volume 2 - Issue 12


Kauverian - Scientific Journals - Volume 3 - Issue 1


Kauverian - Scientific Journals - Volume 3 - Issue 2


Kauverian - Scientific Journals - Volume 3 - Issue 3


Kauverian - Scientific Journals - Volume 3 - Issue 4


Kauverian - Scientific Journals - Volume 3 - Issue 5


Kauverian - Scientific Journals - Volume 3 - Issue 6


Kauverian - Scientific Journals - Volume 3 - Issue 7


Kauverian - Scientific Journals - Volume 3 - Issue 8


Kauverian - Scientific Journals - Volume 3 - Issue 9


Kauverian - Scientific Journals - Volume 3 - Issue 10


Kauverian - Scientific Journals - Volume 3 - Issue 11-1


Kauverian - Scientific Journals - Volume 3 - Issue 11-2


Kauverian - Scientific Journals - Volume 3 - Issue 12


Kauverian - Scientific Journals - Volume 4 - Issue 1


Kauverian - Scientific Journals - Volume 4 - Issue 2


Kauverian - Scientific Journals - Volume 4 - Issue 3


Kauverian - Scientific Journals - Volume 4 - Issue 4


Kauverian - Scientific Journals - Volume 4 - Issue 5


Kauverian - Scientific Journals - Volume 4 - Issue 6


Kauverian - Scientific Journals - Volume 4 - Issue 7


Kauverian - Scientific Journals - Volume 4 - Issue 8


Kauverian - Scientific Journals - Volume 4 - Issue 9


Kauverian - Scientific Journals - Volume 5 - Issue 1


Kauverian - Scientific Journals - Volume 5 - Issue 2


Kauverian - Scientific Journals - Volume 5 - Issue 3


Kauverian - Scientific Journals - Volume 5 - Issue 4


Kauverian - Scientific Journals - Volume 5 - Issue 5


Kauverian - Scientific Journals - Volume 5 - Issue 6


Kauverian - Scientific Journals - Volume 5 - Issue 7


Kauverian - Scientific Journals - Volume 5 - Issue 8


Kauverian - Scientific Journals - Volume 5 - Issue 9


Kauverian - Scientific Journals - Volume 5 - Issue 10


Kauverian - Scientific Journals - Volume 5 - Issue 11


Kauverian - Scientific Journals - Volume 5 - Issue 12


Kauverian - Scientific Journals - Volume 5 - Issue 13

LOCATE US

Find a Doctor Teleconsultation Emergency