Decompressive craniectomy following snakebite envenomation: An uncommon manifestation of a common emergency

Snakebite envenomation remains a neglected tropical disease with significant morbidity and mortality, particularly in rural India. While the neurotoxic and hemorrhagic manifestations of snakebite are well characterized, thrombotic cerebrovascular complications remain rare and underreported. We describe a 47-year-old male farmer who developed rapid neurological deterioration following a snake bite. Despite early administration of polyvalent anti-snake venom and correction of coagulopathy, he presented with deep coma, anisocoria, and radiological evidence of extensive left middle cerebral artery territory infarction with hemorrhagic transformation and midline shift. Laboratory workup revealed disseminated intravascular coagulation (DIC) with a flat thromboelastogram. After aggressive correction of coagulopathy using fresh frozen plasma and cryoprecipitate, the patient underwent emergency left frontotemporoparietal decompressive craniectomy. Intraoperative findings showed diffuse oozing and a tense, non-pulsatile brain. Postoperatively, he demonstrated gradual neurological improvement with normalization of coagulation parameters. Snake venom can precipitate endothelial injury, vasculitis, and paradoxical hypercoagulability, resulting in ischemic stroke and secondary hemorrhagic transformation. The coexistence of DIC poses formidable challenges to surgical management. A literature review revealed only isolated reports of decompressive craniectomy performed in similar settings, underscoring the rarity of this presentation. Snakebite-related cerebrovascular complications, though uncommon, may manifest as acute neurosurgical emergencies. Early recognition of neurological deterioration, timely correction of coagulopathy, and multidisciplinary coordination between intensivists, physicians, and neurosurgeons are critical to achieving favorable outcomes.