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.