Letter to the Editor
Snakebite envenomation-induced posterior reversible encephalopathy syndrome presenting with Bálint syndrome
Síndrome de encefalopatía posterior reversible inducido por mordedura de serpiente debutando como un síndrome de Bálint
Ritwik Ghosha, Moisés León-Ruizb, Shambaditya Dasc, Souvik Dubeyc, Julián Benito-Leónd,e,f,
Corresponding author
a Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
b Section of Clinical Neurophysiology, Department of Neurology, University Hospital La Paz, Madrid, Spain
c Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
d Department of Neurology, University Hospital 12 de Octubre, Madrid, Spain
e Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
f Department of Medicine, Complutense University, Madrid, Spain
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"paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "440" "paginaFinal" => "442" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ritwik Ghosh, Moisés León-Ruiz, Shambaditya Das, Souvik Dubey, Julián Benito-León" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Ritwik" "apellidos" => "Ghosh" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Moisés" "apellidos" => "León-Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Shambaditya" "apellidos" => "Das" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Souvik" "apellidos" => "Dubey" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "Julián" "apellidos" => "Benito-León" "email" => array:1 [ 0 => "jbenitol67@gmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Section of Clinical Neurophysiology, Department of Neurology, University Hospital La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Neurology, University Hospital 12 de Octubre, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Department of Medicine, Complutense University, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de encefalopatía posterior reversible inducido por mordedura de serpiente debutando como un síndrome de Bálint" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1772 "Ancho" => 3341 "Tamanyo" => 930167 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of the brain revealing extensive hyperintensities on T2-fluid-attenuated inversion recovery images involving bilateral parietal, occipital, and frontal lobes, suggestive of posterior reversible encephalopathy syndrome (Fig. 1A) and resolution of those altered intensity lesions after two months following the initial presentation (Fig. 1B).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognised potentially reversible complex neuro-endothelial dysfunction syndrome with a classical neuro-radiological description (i.e., subcortical vasogenic edema) and elusive pathophysiology.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In settings of acute onset neurological deficits in a backdrop of renal failure, blood pressure variability, autoimmune diseases, cytotoxic drugs, pre-eclampsia toxicity, and neuroinfections, the diagnosis of PRES has to be considered.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Only three cases of snakebite envenomation-related PRES have been previously described, but none of them manifested with Bálint syndrome (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Bálint syndrome is a rare and disabling higher-level visual cognitive impairment consisting of a triad of optic ataxia, oculomotor apraxia, and simultanagnosia, usually seen in lesions involving bilateral parieto-occipital cortices, which occurs secondary to a set of diverse conditions, and rarely following PRES.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a previously healthy young Indian woman who presented Bálint syndrome associated with PRES preceded by acute kidney injury and accelerated hypertension following Russell's viper bite.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A previously healthy 24-year-old woman from rural West Bengal (India) was brought to the emergency department due to a Russell's viper bite. The attending physicians promptly recognised the signs of local/systemic envenomation (severe pain, swelling, and regional lymphadenopathy) and started intravenous anti-snake venom infusion (10 vials). Although her initial vital signs were normal and there were no petechiae or purpuric spots, the 20-minute whole blood clotting test was positive. Another ten vials of anti-snake venom were infused. Urinalysis revealed macroscopic haematuria and proteinuria without myoglobinuria. Tests for HIV (1,2), hepatitis viruses, and SARS-CoV-2 were non-reactive. Blood pressure monitoring showed accelerated arterial hypertension, which was resistant to oral and intravenous antihypertensive medications. Furthermore, renal function tests revealed features suggestive of progressive acute kidney injury, for which she was put on serial haemodialysis over the next seven days. Her haemodynamic and laboratory parameters normalised, and she could be discharged home.</p><p id="par0025" class="elsevierStylePara elsevierViewall">However, ten days following discharge, she started needing assistance for everyday activities as she had to struggle to find out objects even if they were within her visual fields. She realised that she could not figure out where the wall ended, and where the door began. Her family members pointed out that even if her mobile phone was kept right in front of her where she left it a while ago, she could not find it.</p><p id="par0030" class="elsevierStylePara elsevierViewall">While entering the clinic, she could not find the entrance as if she was blind. Neuroophthalmological examination revealed that her pupils were equal (3 mm) and reacted normally to light and visual acuities were 20/20 with −2.0 diopter spherical correction in both eyes. Contrast sensitivity and color vision (by Ishihara's chart) were normal. Although she had a full range of voluntary saccades to directional commands, she could not make visually guided saccades to objects. She had severe difficulties in grasping or reaching out for things held in front of her (optic ataxia), an inability to process several visual stimuli or multiple competing sensory stimuli simultaneously (simultanagnosia) and had inability to voluntarily shift/move her eyes to specific objects in her peripheral visual fields and to see fast-moving targets (oculomotor apraxia). All these features were consistent with a diagnosis of Bálint syndrome. The remaining neurological examination was normal. The magnetic resonance imaging of the brain revealed hyperintensities on T2 and T2-fluid-attenuated inversion recovery images involving bilateral parietal, occipital, and frontal lobes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Cerebrospinal fluid analysis for infective and immune-mediated pathologies was negative. Considering the diagnosis of PRES, she was put on high-dose intravenous methylprednisolone. Optic ataxia resolved six days after the initiation of treatment. Simultanagnosia and impaired visually guided saccades resolved after a two-month follow-up. After two months following the initial presentation, MRI of the brain normalised (Fig. 1B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Among documented common complications of snakebite envenomation, haematological, vascular, and neurological ones top the list.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> PRES is a rare but potential complication following Russell's viper envenomation,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> due to either direct toxin-mediated endothelial dysfunction or after secondary hypertensive crisis stemming from toxin-induced renal involvement.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis of Bálint syndrome remains clinically challenging as most patients present with apparent blindness, and history elicitation is difficult.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Oculomotor apraxia, often termed “psychic paralysis of gaze,” is typically unnoticed unless it is specifically looked for.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Again, simultanagnosia, which represents a failure of simultaneous perception of the surrounding environment, may be misinterpreted as a field defect.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Optic ataxia remains elusive, even after meticulous medical history analysis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> So, to pick up Bálint syndrome is necessary a careful clinical examination.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our patient is the first case with PRES presenting as reversible Bálint syndrome following snakebite envenomation. Clinicians should consider PRES when attending patients with visual complaints following snakebite envenomation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Study funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">Nil.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Disclosures</span><p id="par0055" class="elsevierStylePara elsevierViewall">Dr. Ritwik Ghosh (<a href="http://ritwikmed2014@gmail.com">ritwikmed2014@gmail.com</a>) reports no relevant disclosures.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Dr. Moisés León-Ruiz (<a href="http://pistolpete271285@hotmail.com">pistolpete271285@hotmail.com</a>) reports no relevant disclosures.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Dr. Shambaditya Das (<a href="http://drshambadityadas@gmail.com">drshambadityadas@gmail.com</a>) reports no relevant disclosures.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Dr. Souvik Dubey (<a href="http://drsouvik79@gmail.com">drsouvik79@gmail.com</a>) reports no relevant disclosures.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Dr. Julián Benito-León (<a href="http://jbenitol67@gmail.com">jbenitol67@gmail.com</a>) reports no relevant disclosures.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Ethics statement</span><p id="par0080" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient to publish this case report and any accompanying images.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Author contributions</span><p id="par0085" class="elsevierStylePara elsevierViewall">All authors contributed significantly to the creation of this manuscript; each fulfilled criterion as established by the ICMJE.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Study funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Disclosures" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Ethics statement" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Author contributions" ] 4 => array:2 [ "identificador" => "xack672150" "titulo" => "Acknowledgments" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1772 "Ancho" => 3341 "Tamanyo" => 930167 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of the brain revealing extensive hyperintensities on T2-fluid-attenuated inversion recovery images involving bilateral parietal, occipital, and frontal lobes, suggestive of posterior reversible encephalopathy syndrome (Fig. 1A) and resolution of those altered intensity lesions after two months following the initial presentation (Fig. 1B).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author and year of publication \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of snake \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Onset \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antivenom \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical reversibility \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Varalaxmi, 2014<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pit viper \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal and visual impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kaushik, 2014<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Bungaruscaeruleus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, after symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory failure, arterial hypertension, seizures, visual impairment, and motor disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ibrahim, 2017<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cerastesceraste</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Within a week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, before symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coagulopathy and visual impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Partially \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present case, 2022 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Daboia russelii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, after symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal impairment, arterial hypertension, visual impairment, and Bálint syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Summary of clinical and outcome data of four reported cases (including the present one) with snakebite envenomation-induced posterior reversible encephalopathy syndrome. Adapted from Ibrahim et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.E. Fugate" 1 => "A.A. Rabinstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1474-4422(15)00111-8" "Revista" => array:6 [ "tituloSerie" => "Lancet Neurol." 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"fecha" => "2022" "volumen" => "209" "paginaInicial" => "50" "paginaFinal" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35167887" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack672150" "titulo" => "Acknowledgments" "texto" => "<p id="par0090" class="elsevierStylePara elsevierViewall">J. Benito-León is supported by the <span class="elsevierStyleGrantSponsor" id="gs0005">National Institutes of Health, Bethesda, MD, USA</span> (NINDS #<span class="elsevierStyleGrantNumber" refid="gs0005">R01 NS39422</span>), the <span class="elsevierStyleGrantSponsor" id="gs0010">European Commission</span> (grant <span class="elsevierStyleGrantNumber" refid="gs0010">ICT-2011-287739</span>, NeuroTREMOR), <span class="elsevierStyleGrantSponsor" id="gs0015">the Ministry of Economy and Competitiveness</span> (Spain) (grant <span class="elsevierStyleGrantNumber" refid="gs0015">RTC-2015-3967-1</span>, NetMD—platform for the tracking of movement disorder), and <span class="elsevierStyleGrantSponsor" id="gs0020">the Spanish Health Research Agency</span> (grant <span class="elsevierStyleGrantNumber" refid="gs0020">FIS PI12/01602</span> and grant <span class="elsevierStyleGrantNumber" refid="gs0020">FIS PI16/00451</span>).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000003800000006/v1_202306201000/S2173580822000785/v1_202306201000/en/main.assets" "Apartado" => array:4 [ "identificador" => "9409" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000003800000006/v1_202306201000/S2173580822000785/v1_202306201000/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580822000785?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
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| 2024 October | 34 | 8 | 42 |
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