Large vessel occlusion stroke in venom-induced consumption coagulopathy after viper envenomation

Snakebites frequently cause venom-induced consumption coagulopathy (VICC). While bleeding is common, ischaemic stroke from large-vessel occlusion (LVO) is rare. The coexistence of LVO and active VICC creates a therapeutic paradox, as reperfusion therapies risk catastrophic haemorrhage. We report a woman in her mid-60s who developed left-sided hemiplegia 6 hours after a suspected viper bite. Investigations revealed profound VICC and an acute right middle cerebral artery (M1) occlusion. Due to extreme bleeding risks, standard reperfusion therapies—intravenous thrombolysis and mechanical thrombectomy—were contraindicated. Management prioritised rapid venom neutralisation using polyvalent anti-snake venom and supportive care. Once coagulation parameters normalised, cautious antiplatelet therapy was initiated, resulting in partial neurological recovery. This case highlights a rare clinical dilemma where modern stroke treatments are unsafe due to venom-induced coagulopathy, emphasising the necessity of individualised, risk-balanced management when ischaemic and haemorrhagic risks collide.