This study included all the cases of hemorrhagic stroke following snake bite admitted in the neurology Department of Yalgado Ouedraogo University Teaching Hospital during the period from January 1st, 2018 to December 31st 2019.
Cases presentations
Three cases of hemorrhagic stroke following snake bite admitted snake were included in the study.
Case 1
A 55-year-old woman, residing in a rural area 35 km from Ouagadougou, presented on May 21, 2019 with a snake bite on the 5th right toe with associated bleeding at the gingival, abdominal, and left thigh. The patient did not have any past medical history, and the type of snake was unknown. The patient was treated by a traditional healer with scarifications. Twelve days following the initial presentation, she had sudden motor deficit of the left hemi-body preceded by headache, vomiting and fever. She was brought to a local hospital where she received etamsylate injectable, metronidazole injection, paracetamol injectable and ceftriaxone. Anti-snake venom (ASV) and anti-tetanus serum (ATS) were administered in this local hospital. Following admission in the neurology department, the patient presented with hyperthermia a 39 °C, blood pressure at 130/80 mmHg, tachycardia (124 beats per minute), an elevated respiratory rate at (30 cycles per mm), a scar at the level of the lesion, and hematoma of the left thigh. Neurological examination had showed flaccid left hemiplegia with a Medical Research Council score (MRC score) of grade 0 and a National Institute of Health Stroke. Cerebral Computed Tomography showed heterogeneous hyperdensity on internal capsule, lenticular nuclei in right hemisphere and cerebral edema (Fig. 1). The diagnosis of hemorrhagic stroke or venous thrombosis was discussed. The biological assessment found a D-dimer level at 7500 mg / l (15 time normal), a hyperleucocytosis predominantly neutrophilic (14,000 / mm 3), a moderate anemia (9.1 g / l), a negative thick drop, a negative blood culture, an elevated C Reactive protein (95 mg / l), a normal level of creatinine (73.umol / l), a normal level of urea (6 mmol / l), a normal level of Alamine transaminance (22 IU / l), and an elevated level of aspartate transaminance at 45 IU / l. The patient was treated with ceftriaxone 2 g / 24 h, metronidazole 500 mg three time per day. The patient received another dose of anti-snake venom during the 16 day hospitalization. The clinical course was marked by incomplete motor recovery with a MRC score of 0 on the upper limb and 2 on the lower limb.
Case 2
A 16-year-old man, residing in a rural area 135 km from Ouagadougou, without past medical history, was referred to the Emergency Department for a snake bite of undetermined nature on December 12, 2018. The bite was located on the left arm which was completely distorted and painful. At the bite, there was a puntiform and ulcerative bleeding wound. The patient presented to a local medical center with significant bleeding at the insertion site of the venous tract, followed by a loss of consciousness. He had severe anemia (Hemoglobin at 5 g / dl) and received a blood transfusion of 2 blood bags. Following admission in the Infectious disease department, the patient endorsed acute headache without vomiting and constipation. Consciousness was unclear with obnibulation. There the patient had elevated blood pressure at 140/100 mmHg, normal body temperature, normal heart beat and a polypnea of 16 cycles per mm. Local examination revealed swelling of the left side of the upper limb and a lesion suggestive of the bite site. This envenomation was classified as grade 3 according to the Snakebite Severity Score. Biologically, white blood cells were at 7060 / mm3, C reactive protein at 8.39 mg / l, hemoglobin at 9.9 g / dl, VGM at 8.2, MCHC at 30.3, platelet count at 510000 / mm 3. Electrolyte test revealed a serum albumin level at 142.5 mmol / l, potassium at 4.24, calcium at 21.16. HSV serology was negative. After a few days following admission, the patient presented with sudden right hemiparesis (MRC: 0/5 at upper limb and 5/5 at lower limb), cerebellar ataxia and aphasia and then transferred later in the neurology department. The cerebral CT showed bilateral spontaneous frontal and left cerebellar hemorrhage (Fig. 2). The patient was treated with ceftriaxone and received a dose of antivenom serum during this hospitalization of 23 days. The clinical outcome was favorable and the patient recovered completely from this motor deficit.
Case 3
A 30-year-old woman living in a rural area 250 km from Ouagadougou, was admitted on August 19, 2019 in the Neurology Department of Yalgado Ouedraogo University Teaching Hospital or motor deficit on the right hemibody alongside a language disorder. She had no past medical history. The patient was bitten by a snake on the left arm with swelling and bleeding for 10 days, and was treated at home by a traditional healer for a week. After the onset of a sudden motor deficit and consciousness disorder, she was admitted for 4 days at a local hospital where she received antivenom serum, anti-tetanic vaccine, vitamin K, diazepam, and paracetamol. The snake was not identified by peripheral health workers. Despite adequate treatment, the state of consciousness worsened and the patient was transferred at the Neurology Department. General examination at the neurology department revealed elevated blood pressure at 140/90 mmHg, hyperthermia at 39 °C and hematuria with urine color “like coca cola”. Neurological examination had found Broca’s aphasia, left ptosis, Kerning and Brudzinkski signs alongside a 9 on the Glasgow Coma Scale. The dermatological examination showed a pronation stiffness of left upper limb (Fig. 3). Biological investigations had showed urea at 2.69, creatinine at 45.9, hemoglobin at 11 g / dl, white blood cell at 21,000 / mm 3; platelets at 28,000. Alanine transaminase was at 24 IU, aspartate transaminance at 12 IU. Prothrombin level was at 50%. Brain CT scan revealed two heterogeneous temporal hematoma measuring 15 ml and 1.7 ml, perihematomal oedema and left parietal dural hematoma (Fig. 4). The snake bite was classified Grade III according to the WHO classification system. The length of stay was 51 days. During hospitalization, she received blood transfusion of 2 red globular pellet pockets, anti-tetanus serum, anti-snake venom, antibiotic, analgesic and rehydration. The clinical course was favorable to full recovery of consciousness and motor deficit.