Serpent strikes, sapien sways: A rare case of bilateral cerebellar infarct following viper bite

Ischemic stroke following snake bite is rare. We report a posterior circulation infarct involving bilateral cerebellum and occipital lobe following Russell's viper bite in a previously healthy individual. A 50 years old healthy individual, soon after being bitten by the Russel viper on the left foot he developed pain and swelling followed by drooping of eyelids, slurring of speech and giddiness with multiple episodes of vomiting. The patient was administered ASV as well as neostigmine and atropine injections. Following this, the neurological manifestations resolved except dysarthria. CT brain study done was normal. On day 2 of hospitalization, he developed left cerebellar signs (positive finger nose finger test, rebound phenomenon, dysdiadochokinesia, a positive heel shin test). Subsequently, an MRI with MR angiogram was done which showed acute infarcts in bilateral cerebellar hemispheres, with the left superior cerebellar peduncle showing restricted diffusion and low ADC values. Ischemic infarction following viper envenomation has been described by only few authors. In majority of the cases reported, ischemic infarction involved the anterior circulation. The possible mechanisms of infarction in this scenario are discussed. Patient was treated with anti-snake venom and showed a good recovery. Early imaging and early treatment with anti-snake venom is important for a favourable outcome.