Cavernous-carotid artery (CCA) aneurysms represent about 3-5% of all intracranial aneurysms. Spontaneous thrombosis of a CCA aneurysm with simultaneous occlusion of its parent vessel is an extremely rare phenomenon with few reported cases in the literature offering different management strategies. A 54-year-old Asian female presented with a one day-history of painless left eye conjunctival injection, proptosis, and features of cavernous sinus syndrome (cranial nerve III, IV, V1, V2, and VI palsies). Imaging revealed a giant thrombosed CCA aneurysm measuring 3.6cmx3.4cm with complete thrombosis of the left cervical internal carotid artery (ICA) and adequate collaterals from the anterior and posterior communicating artery and branches of the left external carotid artery. Management was conservative with antiplatelet therapy and close clinical-radiological follow-ups. The outcome was satisfactory. Data in the literature on this condition is limited due to its exceedingly rare occurrence. The majority of patients do well via a conservative approach and surgery is rarely indicated. For clinically stable patients, especially those with adequate collateral circulation and tolerance to Balloon Test Occlusion, we advocate for a conservative approach and initiation of anti-platelet therapy to treat these patients. Emphasis is needed on close serial clinicalradiological surveillance in these cases to monitor the propagation of the thrombus as well as the development of new and/or enlarging pre-existing aneurysms in the contralateral ICA circulation.
Background: Gallstone ileus post-cholecystectomy is extremely rare surgical emergency causing mechanical bowel obstruction. This condition is usually misdiagnosed due to its non-specific clinical features. Radiological investigations are essential to evaluate and diagnose gallstone ileus cases.
Case Presentation: A 92-year-old female patient, cholecystomized, presented to our hospital with a one-week history of an acute confusional state, generalized abdominal pain, and vomiting. The physical examination showed a disoriented patient with a distended abdomen and generalized tenderness, especially in the epigastric area. Hyperactive bowel sounds were audible. Laboratory investigations were non-specific. A plain abdominal X-ray was insignificant. The abdominal ultrasound showed marked abdominal gaseous distention. Then, an abdominal CT scan was performed, revealing an impression of gallstone ileus causing small bowel obstruction with no evidence of fistula formation. So, surgical intervention was decided, and an 8-gram gallstone was exteriorized through an enterolithotomy. The postoperative period was uneventful.
Discussion: Gallstone ileus is an unusual entity that often affects elderly females. The clinical features of gallstone ileus include abdominal pain, abdominal distension, nausea, and vomiting. Diagnosis of gallstone ileus relies on imaging and physical examination. Abdominal CT with contrast provides a definitive diagnostic tool. The surgical options to manage the gallstone ileus can be either one or two-staged enterolithotomy.
Conclusion: Due to the rare etiologic origin of the gallstone ileus in post-cholecystectomy cases, we report the case of a 92-year-old female with an acute confusional state and generalized abdominal pain, found to be caused by detected gallstone ileus, lacking evidence of fistula formation.
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