Skip to main content Accessibility help
×
Home

Cerebrovascular Injury Following Scorpion Sting and Snake Envenomation: A Case Series

  • Ajay Mishra (a1), Aditya Binu (a2), George Abraham (a3), Harshad Vanjare (a4), Tina George (a5) and Ramya Iyadurai (a1)...

Abstract

Background

Neurological complications following snake and scorpion bite are diverse. Literature regarding patterns of cerebrovascular injury (CVI) and outcomes among these patients is scarce. This is a descriptive study of the clinical profile, brain imaging findings, mechanisms of injury, vascular territory involvement and outcomes of CVI following scorpion and snake envenomation, in a tertiary care center in South India.

Methodology

Patients with scorpion sting- and snake envenomation-related complications were retrospectively enrolled. Neuroimaging was performed on five patients with each envenomation, and they were found to have neurological involvement. On imaging, three patients were found to have a CVI. Clinical, radiological parameters and outcomes of these patients were studied. We also performed a review of the literature and analyzed the finding of all the cases.

Result

In all, three patients each had evidence of CVI in imaging. An additional 32 reports of scorpion sting-related CVI and 35 reports of snake envenomation-related CVI were identified from the literature. There was a male predominance among these patients. Mean age of the patients with scorpion sting was 42.8 years as compared with 33 years for the patients with snake envenomation. Features of severe envenomation were present in all patients. Persistently depressed sensorium and new-onset focal neurological deficits were seen in 70% of all patients. Infarcts were seen in 88% of patients with snake envenomation and 53% of patients with a scorpion sting. Mortality was 28% among patients with a scorpion sting as compared with 8% with snake envenomation.

Conclusion

Cerebrovascular injuries are uncommon neurological manifestations following scorpion and snake envenomation. These tend to occur in younger patients. Infarcts are more common than bleeds.

Des lésions cérébrovasculaires consécutives à des piqûres de scorpion et à des morsures de serpent : une série de cas.Contexte : Les complications d’ordre neurologique à la suite de piqûres de scorpion et de morsures de serpent sont diverses. À cet égard, rares sont les publications scientifiques portant sur les types de lésions cérébrovasculaires (LCV) induites par ces animaux et sur l’évolution de l’état de santé des patients qui en ont été victimes. Objectif: Dans un centre de soins tertiaires du sud de l’Inde, mener une étude descriptive tenant compte des aspects suivants à la suite de l’envenimation d’individus causée par un serpent ou un scorpion : le profil clinique des patients, les résultats d’une imagerie cérébrale, les mécanismes associés aux lésions cérébrales, le territoire vasculaire concerné et les conséquences de la ou des LCV encourues. Méthodologie: Des patients atteints de complications consécutives à une envenimation causée par un scorpion ou un serpent ont ainsi été recrutés de façon rétrospective. Cinq patients victimes chacun d’une envenimation ont présenté des complications neurologiques et ont bénéficié d’un examen de neuro-imagerie. Trois d’entre eux ont présenté une LCV lors d’un tel examen. Ont été étudiés les paramètres cliniques et radiologiques de ces patients de même que l’évolution de leur condition médicale. Nous avons aussi effectué une revue de littérature et analysé les résultats propres à chaque cas. Résultats: On l’a dit, trois patients ont montré chacun des signes de LCV lors d’un examen de neuro-imagerie. De plus, 32 cas de patients atteints de LCV attribuables à des piqûres de scorpion et 35 cas de patients atteints de LCV liés à une envenimation induite par des morsures de serpent ont été identifiés dans des publications scientifiques. La majorité de ces patients était de sexe masculin. L’âge moyen des patients victimes de piqûres de scorpion était de 42,8 ans alors que ceux victimes d’une envenimation causée par des morsures de serpent avaient en moyenne 33 ans. Les caractéristiques typiques d’une grave envenimation étaient présentes chez tous les patients. Un sensorium affaibli de façon durable et l’apparition de nouveaux déficits neurologiques ont été notés chez 70 % des patients. Des infarctus ont aussi été observés chez 88 % des patients victimes d’une envenimation induite par des morsures de serpent et chez 53 % des patients ayant été piqués par un scorpion. Enfin, le taux de mortalité a été de 8 % pour tous ces patients. Conclusions: On peut dire que des LCV constituent, à la suite de cas d’envenimation induite par un scorpion ou un serpent, des affections neurologiques inhabituelles. Ces dernières ont surtout tendance à survenir chez des patients plus jeunes. Notons de surcroît que des infarctus demeurent plus fréquents que des saignements.

Copyright

Corresponding author

Correspondence to: A. Mishra, Unit V, Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, India. Email: ajaybalasore@gmail.com

References

Hide All
1. Elkhayari, M, Hachimi, A, Ziadi, A, Abdenasser Samkaoui, M. Ischemic stroke following a scorpion sting. Rev Neurol (Paris). 2013;169(6–7):519-522.
2. Gawarammana, I, Mendis, S, Jeganathan, K. Acute ischemic strokes due to bites by Daboia russelii in Sri Lanka - first authenticated case series. Toxicon. 2009;54(4):421-428.
3. Lee, BC, Hwang, SH, Bae, JC, Kwon, SB. Brainstem infarction following Korean viper bite. Neurology. 2001;56(9):1244-145.
4. Nagaraja, D, Verma, A, Taly, AB, Kumar, MV, Jayakumar, PN. Cerebrovascular disease in children. Acta Neurol Scand. 1994;90(4):251-255.
5. Del Brutto, OH, Del Brutto, VJ. Scorpion stings: focus on cerebrovascular complications of envenoming. Int J Stroke. 2013;8(4):E8.
6. Narang, SK, Paleti, S, Asad, MA, Samina, T. Acute ischemic infarct in the middle cerebral artery territory following a Russell’s viper bite. Neurol India. 2009;57(4):479-480.
7. Mahale, R, Mehta, A, Javali, M, Srinivasa, R. A case of bilateral occipital lobe infarcts following Indian tree viper bite. J Stroke. 2014;16(3):205-207.
8. Hoskote, SS, Iyer, VR, Kothari, VM, Sanghvi, DA. Bilateral anterior cerebral artery infarction following viper bite. J Assoc Physicians India. 2009;57:67-69.
9. Paul, G, Paul, BS, Puri, S. Snake bite and stroke: our experience of two cases. Indian J Crit Care Med. 2014;18(4):257-258.
10. Subasinghe, CJ, Sarathchandra, C, Kandeepan, T, Kulatunga, A. Bilateral blindness following Russell’s viper bite - a rare clinical presentation: a case report. J Med Case Rep. 2014;8:99.
11. Namal Rathnayaka, RMMK, Kularatne, SAM, Kumarasinghe, KDM, Ranaweera, J, Nishanthi Ranathunga, PEA. Ischemic brain infarcts and intracranial haemorrhages following Russell’s viper (Daboia russelii) bite in Sri Lanka. Toxicon. 2017;125:70-73.
12. 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(4):301-303.
13. Eze, C, Onwuekwe, I, Ekenze, O. Stroke as a rare consequence of scorpion sting and scorpion ingestion: a case report from South East Nigeria. Ann Trop Med Public Health. 2014;7(4):202-205.
14. Kochar, DK, Singh, P, Sharma, BV, Saini, G, Aggarwal, P, Gauri, LA. Scorpion envenomation causing hemiparesis. J Assoc Physicians India. 2002;50:606-607.
15. Jain, MK, Indurkar, M, Kastwar, V, Malviya, S. Myocarditis and multiple cerebral and cerebellar infarction following scorpion sting. J Assoc Physicians India. 2006;54:491-492.
16. Rebahi, H, Nejmi, H, Abouelhassan, T, Hasni, K, Samkaoui, M-A. Severe envenomation by cerastes cerastes viper: an unusual mechanism of acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014;23(1):169-172.
17. Merle, H, Donnio, A, Ayeboua, L, Plumelle, Y, Smadja, D, Thomas, L. Occipital infarction revealed by quadranopsia following snakebite by Bothrops lanceolatus . Am J Trop Med Hyg. 2005;73(3):583-585.
18. Bush, SP, Mooy, GG, Phan, TH. Catastrophic acute ischemic stroke after crotalidae polyvalent immune Fab (ovine)-treated rattlesnake envenomation. Wilderness Environ Med. 2014;25(2):198-203.
19. Sarkar, S, Bhattacharya, P, Paswan, A. Cerebrovascular manifestations and alteration of coagulation profile in scorpion sting: a case series. Indian J Crit Care Med. 2008;12(1):15-17.
20. Malliboina, S, Mahesh, V, Agrawal, A. Progressive hemiparesis following scorpion sting in a female with uncontrolled hypertension. West Afr J Radiol. 2014;21(2):85-86.
21. Udayakumar, N, Rajendiran, C, Srinivasan, AV. Cerebrovascular manifestations in scorpion sting: a case series. Indian J Med Sci. 2006;60(6):241-244.
22. Gadwalkar, SR, Bushan, S, Pramod, K, Gouda, C, Kumar, PM. Bilateral cerebellar infarction: a rare complication of scorpion sting. J Assoc Physicians India. 2006;54:581-583.
23. Cañas, CA. Brainstem ischemic stroke after to Bothrops atrox snakebite. Toxicon. 2016;120 (Suppl C):124-127.
24. Ittyachen, AM, Jose, MB. Thalamic infarction following a Russell’s viper bite. Southeast Asian J Trop Med Public Health. 2012;43(5):1201-1204.
25. Mosquera, A, Idrovo, LA, Tafur, A, Del Brutto, OH. Stroke following Bothrops spp. snakebite. Neurology. 2003;60(10):1577-1580.
26. Sengupta, S, Dhanapal, P, Ravindran, RD, Devi, N. Cerebral blindness after scorpion sting. J Neuroophthalmol. 2009;29(2):154-155.
27. Raichur, DV, Magar, VS, Wari, PK, Chandragouda, DK. Hemiplegia and motor aphasia following scorpion sting. Indian J Pediatr, 68(7):669-670.
28. Vale, TC, Leite, AF, da Hora, PR, Coury, MIF, da Silva, RC, Teixeira, AL. Bilateral posterior circulation stroke secondary to a crotalid envenomation: case report. Rev Soc Bras Med Trop. 2013;46(2):255-256.
29. Gupta, S, Tewari, AK, Nair, V. Cerebellar infarct with neurogenic pulmonary edema following viper bite. J Neurosci Rural Pract. 2012;3(1):74-76.
30. Mishra, AK, Arvind, VH, Muliyil, D, et al. Cerebrovascular injury in cryptococcal meningitis. Int J Stroke. 2018;13:57-65.
31. Kumar, RM, Babu, RP, Agrawal, A. Multiple infarctions involving cerebral and cerebellar hemispheres following viper bite. J Med Soc. 2015;29:51-53.
32. Boviatsis, EJ, Kouyialis, AT, Papatheodorou, G, Gavra, M, Korfias, S, Sakas, DE. Multiple hemorrhagic brain infarcts after viper envenomation. Am J Trop Med Hyg. 2003;68(2):253-257.
33. Krishna, PV, Ahmed, S, Reddy, KVN. Ischemic stroke consequent to snake bite. J NTR Univ Health Sci. 2017;6(3):192.
34. Godpower, MC. Cerebellar infarct with neurogenic pulmonary edema following viper bite. J Neurosci Rural Pract. 2012;3(1):4-5.
35. Fernández-Bouzas, A, Morales-Reséndiz, ML, Llamas-Ibarra, F, Martínez-López, M, Ballesteros-Maresma, A. Brain infarcts due to scorpion stings in children: MRI. Neuroradiology. 2000;42(2):118-120.
36. Dube, S, Sharma, VK, Dubey, TN, Gouda, NB, Shrivastava, V. Fatal intracerebral haemorrhage following scorpion sting. J Indian Med Assoc. 2011;109(3):194-195.
37. Bucaretchi, F, Capitani, EMD, Fernandes, CB, Santos, TM, Zamilute, IAG, Hyslop, S. Fatal ischemic stroke following Tityus serrulatus scorpion sting in a patient with essential thrombocythemia. Clin Toxicol. 2016;54(9):867-870.
38. Tiwari, SK, Gupta, GB, Gupta, SR, Mishra, SN, Pradhan, PK. Fatal stroke following scorpion bite. J Assoc Physicians India. 1988;36(3):225-226.
39. Thacker, AK, Lal, R, Misra, M. Scorpion bite and multiple cerebral infarcts. Neurol India. 2002;50(1):100-102.
40. Thomas, VV, George, T, Mishra, AK, Mannam, P, Ramya, I. Lateral medullary syndrome after a scorpion sting. J Family Med Prim Care. 2017;6:155-157.
41. Chandrashekar, D, Anikethana, GV, Kalinga, BE. Viper bite presenting as acute ischemic stroke. Int J Sci Res. 2014;11(3):319-321.

Keywords

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed