Early Recognition of a Dual Acute Emergency: Concurrent Ischemic Stroke and Suspected Sigmoid Volvulus in a Chronically Immobile Older Adult: A Case Report

Abstrak

Introduction: In elderly patients presenting with acute altered consciousness, clinical attention is often directed primarily toward the neurological system, particularly when there is a previous history of stroke. Such a narrowly focused diagnostic approach may result in delayed recognition of a concurrent medical emergency outside the neurological system. We report a case in which early and systematic clinical assessment enabled the timely identification of two simultaneous acute emergencies—acute ischemic stroke and suspected sigmoid volvulus—in an elderly patient with chronic immobility.

Case Presentation: A 72-year-old woman with a history of previous ischemic stroke with complete recovery, diabetes mellitus and hypertension that had remained untreated for a prolonged period, and chronic immobility secondary to a lower-extremity fracture presented with progressive altered consciousness for 20 hours. In addition to the neurological symptoms, her family reported worsening constipation for one month that had not responded to laxative therapy, ultimately resulting in complete inability to tolerate oral intake for three days before hospital admission. Neurological examination revealed a Glasgow Coma Scale (GCS) score of 9 (E2V2M5) with left-sided lateralizing signs. Despite the predominantly neurological presentation, abdominal examination was also performed and revealed abdominal distension, tenderness, and decreased bowel sounds. These findings prompted an initial diagnostic evaluation encompassing both neurological and gastrointestinal systems. Non-contrast head computed tomography (CT) confirmed acute ischemic infarctions involving the right centrum semiovale, left thalamus, and left pons, while abdominal radiography demonstrated a characteristic “coffee bean” appearance and “step-ladder” sign consistent with sigmoid volvulus. The patient was promptly stabilized and referred to a tertiary-care center with digestive surgical facilities for definitive management of both acute conditions.

Conclusion: This case highlights the importance of early, systematic examination beyond the presenting neurological complaint in elderly patients with altered consciousness, particularly those with risk factors for chronic immobility and gastrointestinal dysfunction. Early recognition of a concurrent non-neurological emergency can substantially influence triage priorities, resuscitation strategies, and the urgency of referral, underscoring the value of a holistic diagnostic approach in the emergency care of vulnerable geriatric patients.