Endovascular Therapy for Acute Stroke with a Large Ischemic Region.

BACKGROUND: Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied. METHODS: We conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours. RESULTS: A total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P = 0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001). CONCLUSIONS: In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.).

A woman in her thirties with dyspnoea two weeks after abdominoplasty. / En kvinne i 30-årene med dyspné to uker etter bukplastikkoperasjon.

Background: While most cases of venous thromboembolism follow a benign course, occasionally the condition may manifest a complex clinical presentation and need a comprehensive diagnostic workup to identify the underlying cause and provide the patient with appropriate treatment. Case presentation: A woman in her late thirties presented to the emergency department with a five-day history of dyspnoea. She had recently undergone liposuction surgery after pregnancy. Upon admission, initial investigations revealed a pulmonary embolism with right heart strain, and she was treated with anticoagulants. The following day, she complained of acute-onset right flank pain without fever or other accompanying symptoms. A CT scan of the abdomen confirmed a right-side renal infarction. Further investigations revealed patent foramen ovale between the right and left atria of the heart, believed to be the source of a right-to-left shunt of arterial emboli. Although the patient had not suffered a clinical stroke, it was decided to close this defect using percutaneous technique. Interpretation: Patent foramen ovale is a common condition in adults, but in most cases it remains asymptomatic. However, patients with patent foramen ovale have an elevated risk of arterial emboli affecting multiple organs. The diagnosis depends on thorough assessment to prevent potentially fatal outcomes.

Wavefront directionality and decremental stimuli synergistically improve identification of ventricular tachycardia substrate: insights from personalized computational heart models.

AIMS: Multiple wavefront pacing (MWP) and decremental pacing (DP) are two electroanatomic mapping (EAM) strategies that have emerged to better characterize the ventricular tachycardia (VT) substrate. The aim of this study was to assess how well MWP, DP, and their combination improve identification of electrophysiological abnormalities on EAM that reflect infarct remodelling and critical VT sites. METHODS AND RESULTS: Forty-eight personalized computational heart models were reconstructed using images from post-infarct patients undergoing VT ablation. Paced rhythms were simulated by delivering an initial (S1) and an extra-stimulus (S2) from one of 100 locations throughout each heart model. For each pacing, unipolar signals were computed along the myocardial surface to simulate substrate EAM. Six EAM features were extracted and compared with the infarct remodelling and critical VT sites. Concordance of S1 EAM features between different maps was lower in hearts with smaller amounts of remodelling. Incorporating S1 EAM features from multiple maps greatly improved the detection of remodelling, especially in hearts with less remodelling. Adding S2 EAM features from multiple maps decreased the number of maps required to achieve the same detection accuracy. S1 EAM features from multiple maps poorly identified critical VT sites. However, combining S1 and S2 EAM features from multiple maps paced near VT circuits greatly improved identification of critical VT sites. CONCLUSION: Electroanatomic mapping with MWP is more advantageous for characterization of substrate in hearts with less remodelling. During substrate EAM, MWP and DP should be combined and delivered from locations proximal to a suspected VT circuit to optimize identification of the critical VT site.

Non-invasive localization of post-infarct ventricular tachycardia exit sites to guide ablation planning: a computational deep learning platform utilizing the 12-lead electrocardiogram and intracardiac electrograms from implanted devices.

AIMS: Existing strategies that identify post-infarct ventricular tachycardia (VT) ablation target either employ invasive electrophysiological (EP) mapping or non-invasive modalities utilizing the electrocardiogram (ECG). Their success relies on localizing sites critical to the maintenance of the clinical arrhythmia, not always recorded on the 12-lead ECG. Targeting the clinical VT by utilizing electrograms (EGM) recordings stored in implanted devices may aid ablation planning, enhancing safety and speed and potentially reducing the need of VT induction. In this context, we aim to develop a non-invasive computational-deep learning (DL) platform to localize VT exit sites from surface ECGs and implanted device intracardiac EGMs. METHODS AND RESULTS: A library of ECGs and EGMs from simulated paced beats and representative post-infarct VTs was generated across five torso models. Traces were used to train DL algorithms to localize VT sites of earliest systolic activation; first tested on simulated data and then on a clinically induced VT to show applicability of our platform in clinical settings. Localization performance was estimated via localization errors (LEs) against known VT exit sites from simulations or clinical ablation targets. Surface ECGs successfully localized post-infarct VTs from simulated data with mean LE = 9.61 ± 2.61 mm across torsos. VT localization was successfully achieved from implanted device intracardiac EGMs with mean LE = 13.10 ± 2.36 mm. Finally, the clinically induced VT localization was in agreement with the clinical ablation volume. CONCLUSION: The proposed framework may be utilized for direct localization of post-infarct VTs from surface ECGs and/or implanted device EGMs, or in conjunction with efficient, patient-specific modelling, enhancing safety and speed of ablation planning.

Long-term success of a multi-electrode substrate mapping and ablation strategy versus a classic single tip mapping and ablation strategy for ventricular tachycardia ablation in patients with ischemic cardiomyopathy.

INTRODUCTION: Over the past years, mapping and ablation techniques for the treatment of ventricular tachycardia (VT) have evolved rapidly. High Density (HD) substrate mapping is now routine and pre-procedural imaging is increasingly used. The additional value of these techniques for long-term VT-free survival is not clear. METHODS: We compared baseline and procedural characteristics, procedural success, safety and outcome of mapping and ablation of ventricular tachycardia in patients with ischemic heart disease between two groups. (1) Low Density (LD) group: VT mapping and ablation with a 4 mm single tip catheter (2) HD group: HD substrate mapping with the Pentaray (Biosense Webster, USA) or HD Grid (Abbott, USA) catheter and ablation with a 4 mm single tip catheter. RESULTS: VT ablation was performed in 133 patients (71 patients in LD group and 62 patients in HD group). The median follow-up was 5.0 years in LD group and 2.0 years in HD group. One-, two-, and five-year VT recurrence rates were 47%, 56%, and 65% in the LD group versus 39%, 50%, and 55% in the HD group (log-rank test for VT recurrence p = .70). One-, two-, and five-year ICD shock recurrence rates were 14%, 18%, and 24% in the LD group versus 8%, 15%, and 19% in the HD group (log-rank test for ICD-shock p = .79). All-cause mortality, cardiac (non-arrhythmic), and arrhythmic death, were similar in both groups. Severe procedural complications (tamponade, stroke, or procedural death) occurred in four patients (5%, 1 vascular, 3 tamponade) in the LD group versus two patients (3%, both tamponade) in the HD group (NS). In univariate and multivariable analysis, only a higher LVEF was significantly associated with VT-free survival. HD mapping was not significantly associated with VT-free survival. Anterior infarct location and age were significantly associated with ICD recurrent shock in both univariate and multivariable analyses. CONCLUSIONS: In patients with ischemic cardiomyopathy, a HD substrate mapping, and ablation strategy did not lead to higher VT-free survival and shock-free survival compared to a single tip mapping and ablation strategy. In this study, only LVF is an independent predictor for VT recurrence. Anterior infarct location and age predict recurrent ICD shocks.

Premammillary artery infarction after microsurgical clipping of unruptured posterior communicating artery aneurysm: risk factors and surgical and anatomical considerations.

Posterior communicating artery (PCoA) aneurysm is common and sometimes requires microsurgery; however, as data on premammillary artery (PMA) infarction after clipping is scarce, we retrospectively reviewed cases of post-clipping PMA infarction to analyze incidence, independent risk factors of infarction, and anatomical considerations. Data from 569 consecutive patients who underwent microsurgical clipping for unruptured PCoA aneurysm between January 2008 and December 2020 were included. Patients were categorized into the normal or the PMA infarction group. Statistical analyses and comparisons between the two groups were used to determine the influence of various factors. The normal group included 515 patients while the PMA infarction group had 31. The mean length of hospital stay was significantly longer in the PMA infarction group (10.3 ± 9.1 days) than in the normal group (6.5 ± 6.4 days; p < 0.0001). The distribution of Glasgow Outcome Scale at discharge was significantly different between the two groups (p ≤ 0.0001) but was not so at 6 months after discharge (p = 0.0568). Multivariate logistic regression analysis identified aneurysm size (odds ratio [OR], 1.194; 95% confidence interval [CI], 1.08-1.32; p = 0.0005) and medial direction of aneurysm (OR, 4.615; 95% CI, 1.224-17.406; p = 0.0239) as independent risk factors of post-clipping PMA infarction. Surgeons must beware of PMA infarction after clipping of large aneurysms that are medial in direction. Intraoperative verification of the patency of the PCoA and the PMA from various angles using various intraoperative methods can reduce morbidity due to PMA infarction.

[Testicular cavernous hemangioma associated with testicular torsion: A case report and review of the literature].

OBJECTIVE: To explore the clinical diagnosis and treatment of testicular cavernous hemangioma (TCH). METHODS: We retrospectively analyzed the clinical data on a case of TCH associated with testicular torsion treated in our hospital and reviewed the relevant literature. RESULTS: The patient underwent "right orchiectomy" after preoperative examinations. Intraoperative pathology indicated testicular parenchyma infarction, and postoperative pathology showed cavernous hemangioma with hemorrhage and infarction. No recurrence was observed during 3 years of postoperative follow-up. CONCLUSION: Testicular cavernous hemangioma is an extremely rare benign tumor of the testis, and rarely associated with testicular torsion. Preoperative and intraoperative pathology provides a basis for the selection of reasonable treatment.

IDIOPHATIC ASYNCHRONOUS BILATERAL SEGMENTAL TESTICULAR INFARCTION AND ANTICOAGULANT THERAPY: A CASE REPORT.

We present an unusual case of sudden onset of pain in the left testis in a patient with a previous medical history of right orchiectomy due to hemorrhagic infarction. A partial orchiectomy was performed with complete removal of the lesion and reconstruction of the testicular parenchyma. Histopathological assessment confirmed segmental testicular infarction without the presence of malignancy. The patient subsequently received anticoagulant therapy.

The American Association for the Surgery of Trauma Renal Grading System-Should Segmental Kidney Infarction be Classified as a Grade IV Injury?

PURPOSE: In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction. METHODS: We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction. RESULTS: From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions. CONCLUSIONS: Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

[Renal Artery Stenting for Spontaneous Renal Artery Dissection with Renal Infarction].

Spontaneous renal artery dissection (SRAD) is extremely rare and the management procedures have not been established. We report a case of endovascular stent placement for SRAD with renal infarction. A 53-year-old man visited a hospital with the complaint of lumbago. Contrast enhanced computed tomography images showed right renal artery dissection and renal infarction. He was transferred to our hospital for further treatment. We consulted our department of endovascular surgery. As 16 hours had passed from the onset, stent placement was performed on the next day as a wait and see procedure. He was discharged 11 days after the stenting. At 14 months after the procedure, he is free from lumbago and his serum creatine levels are within the normal range.

Hybrid Therapy Consisting of Bowel Resection and Fluoroscopic-Assisted Balloon Thrombectomy for Small Bowel Infarction Caused by Acute Mesenteric Venous Thrombosis.

BACKGROUND: To investigate the effect of bowel resection combined with fluoroscopic-assisted balloon thrombectomy for small bowel infarction caused by acute mesenteric venous thrombosis (AMVT). METHODS: Between June 2016 and August 2017, nine patients (seven males and two females; range, 40-73 years; mean, 55.11 ± 10.08 years) with small bowel infarction caused by AMVT underwent bowel resection combined with fluoroscopic-assisted balloon thrombectomy. The demographics, risk factors, therapeutic effect, complications, mortality, and follow-up of the study population were assessed. RESULTS: The effective rate was 100% with substantial clinical improvement in symptoms. All patients underwent small bowel resection with primary anastomosis. The length of bowel resection ranged from 60 to 170 cm (108.67 ± 35.05). In none of the cases there was surgery with second look. The patients were discharged 13-42 days (20.11 ± 8.75) after admission without perioperative complication or death. The follow-up period was 8-21 months (12.89 ± 4.65), and the follow-up rate was 100%. All patients returned to normal activities, regained lost body weight, and remained asymptomatic during the follow-up period. CONCLUSIONS: The combination therapy of bowel resection and fluoroscopic-assisted balloon thrombectomy is technically feasible and may be beneficial for small bowel infarction caused by AMVT in removing a thrombus efficiently, relieving symptoms rapidly, averting second-look surgery, lowering extensive surgical resections, and improving the prognosis.

A Neonate with Bilateral Vitreous Hemorrhages After Intra-uterine Bowel Infarction Secondary to Volvulus.

Vitreous hemorrhages are uncommon in the neonatal period. This article describes a neonatal who had bilateral vitreous hemorrhages after intrauterine bowel infarction.

Clinical implications of CT findings in mesenteric venous thrombosis at admission.

PURPOSE: The main aim of this study was to evaluate the association of computed tomography (CT) findings at admission and bowel resection rate in patients with mesenteric venous thrombosis (MVT). It was hypothesized that abnormal intestinal findings on CT were associated with a higher bowel resection rate. METHODS: Retrospective study of MVT patients treated between 2004 and 2017. CT images at admission and at follow-up were scrutinized according to a predefined protocol. Successful recanalization was defined as partial or complete recanalization of the portomesenteric venous thrombosis at the latest CT follow-up (n = 70). RESULTS: We studied 102 patients (median age 58 years, 61 men). Lifelong anticoagulation was initiated in 64 patients, and bowel resection rate was 17%. No referral letter indicated suspicion of MVT, whereas three indicated suspected intestinal ischemia. Previous venous thromboembolism was associated with increased bowel resection rate (p = 0.049). No patient with acute pancreatitis (n = 17) underwent bowel resection (p = 0.068). The presence of mesenteric oedema (p = 0.014), small bowel wall oedema (p < 0.001), small bowel dilatation (p = 0.005), and ascites (p = 0.021) were associated with increased bowel resection rate. Small bowel wall oedema remained as an independent risk factor associated with bowel resection (OR 15.8 [95% CI 3.2-77.2]). Successful thrombus recanalization was achieved in 66% of patients. CONCLUSION: The presence of abnormal intestinal findings secondary to MVT confers an excess risk of need of bowel resection due to infarction. Responsible physicians should therefore scrutinize the CT images at diagnosis together with the radiologist to better tailor clinical surveillance.

Axial Torsion and Infarction of Meckel\'s Diverticulum in the 3rd Trimester of Pregnancy.

Meckel's diverticulum is a congenital anomaly which can become complicated or remain asymptomatic throughout life. During pregnancy, however, diverticulum infection could become a serious complication. Diverticulum necrosis and perforation are complications that increase morbidity in pregnancy, both maternal and fetal. The rarity of the condition and the maternal physiological changes in pregnancy make the diagnosis difficult. We present the case of a Meckel's diverticulum gangrene in third trimester pregnancy, atypical case due to advanced pregnancy where the risk-benefit balance was carefully evaluated on one hand because of the risk of infection associated with expectant management and on the other hand the risk and complications of iatrogenic preterm premature birth. The outcome was favorable for both mother and newborn.

Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia: Prospective Study from an Intestinal Stroke Center.

OBJECTIVES: To identify predictive factors for irreversible transmural intestinal necrosis (ITIN) in acute mesenteric ischemia (AMI) and establish a risk score for ITIN. METHODS: This single-center prospective cohort study was performed between 2009 and 2015 in patients with AMI. The primary outcome was the occurrence of ITIN, confirmed by specimen analysis in patients who underwent surgery. Patients who recovered from AMI with no need for intestinal resection were considered not to have ITIN. Clinical, biological and radiological data were compared in a Cox regression model. RESULTS: A total of 67 patients were included. The origin of AMI was arterial, venous, or non-occlusive in 61%, 37%, 2% of cases, respectively. Intestinal resection and ITIN concerned 42% and 34% of patients, respectively. Factors associated with ITIN in multivariate analysis were: organ failure (hazard ratio (HR): 3.1 (95% confidence interval (CI): 1.1-8.5); P=0.03), serum lactate levels >2 mmol/l (HR: 4.1 (95% CI: 1.4-11.5); P=0.01), and bowel loop dilation on computerized tomography scan (HR: 2.6 (95% CI: 1.2-5.7); P=0.02). ITIN rate increased from 3% to 38%, 89%, and 100% in patients with 0, 1, 2, and 3 factors, respectively. Area under the receiver operating characteristics curve for the diagnosis of ITIN was 0.936 (95% CI: 0.866-0.997) depending on the number of predictive factors. CONCLUSIONS: We identified three predictive factors for irreversible intestinal ischemic injury requiring resection in the setting of AMI. Close monitoring of these factors could help avoid unnecessary laparotomy, prevent resection, as well as complications due to unresected necrosis, and possibly lower the overall mortality.

Nonocclusive mesenteric infarction after cardiac surgery: potential biomarkers.

BACKGROUND: Nonocclusive mesenteric ischemia can cause intestinal infarction but the diagnosis is challenging. This prospective study evaluated three plasma biomarkers of intestinal infarction after cardiac surgery. MATERIALS AND METHODS: Patients were recruited after cardiac surgery if they required laparotomy (with or without intestinal resection) for suspected nonocclusive mesenteric ischemia. Plasma levels of D-lactate, intestinal fatty acid-binding protein (i-FABP), and smooth muscle actin (SMA) before laparotomy were measured. RESULTS: Twenty patients were recruited (68 ± 9 y, EuroSCORE: 8.7 ± 2.8, mortality 70%). A positive laparotomy (n = 13) was associated with no change in D-lactate (P = 0.95), decreased i-FABP (P = 0.007), and increased SMA (P = 0.01). All patients with high SMA had a positive laparotomy. A subgroup analysis was undertaken in the eight patients who required multiple laparotomies. D-lactate increased between the two laparotomies in nonsurvivors (n = 4). Plasma i-FABP (P = 0.008) and SMA (P = 0.036) significantly decreased after the bowel resection, regardless of survival outcome. CONCLUSIONS: None of the biomarkers were accurate enough to reliably diagnose intestinal infarction. However, all patients with high values of SMA developed intestinal infarction, thus warranting further investigation. An increasing D-lactate after intestinal resection suggests impending death.

Paediatric spinal cord infarction-a review of the literature and two case reports.

Ischemic spinal cord infarction is rare in the paediatric population, and when it does occur, it is usually associated with traumatic injury. Other potential causes include congenital cardiovascular malformations, cerebellar herniation, thromboembolic disease and infection. Magnetic resonance imaging (MRI) findings can be subtle in the early evaluation of such patients. The outcome is variable and depends on the level and extent of the spinal cord infarct and subsequent rehabilitation. Here, we present two cases of ischemic spinal cord infarction in children.

Case Report: What is Your Differential Diagnosis for Bilateral Cerebellar Infarct?

Neurovascular variants are not frequently described outside of specialty literature. Infarction involving these atypical neurovascular structures present with unusual clinical findings and radiologic imaging. A 63-year-old man with hypertension, diabetes, and former tobacco use presented from the Department of Corrections with global headache, nausea, vomiting, and double vision. He was found to be hypertensive to 240/120. CT imaging noted acute ischemic changes in the bilateral posterior inferior cerebellar artery distribution. Follow up 3-D time-of-flight (TOF) magnetic resonance angiography (MRA) of the cranial region demonstrated abrupt cut off of an azygous right posterior inferior cerebellar artery (PICA) and presumed absence of the left PICA. The patient underwent occipital craniotomy for evolving ischemic stroke and development of hydrocephalus, and ultimately recovered without neurologic deficits.

[Asynchronous Bilateral Testicular Infarction with Suspected Polyarteritis Nodosa : A Case Report].

This report documents a case of asynchronous bilateral testicular infarction. The patient was a 42- year-old man who presented with left testicular pain and swelling. He had a past history of right idiopathic testicular infarction and underwent a right orchiectomy 6 years ago. He also had received treatment for 5 years for suspected polyarteritis nodosa (PAN). The left scrotal pain persisted for a week and left orchiectomy was performed. Pathological evaluations demonstrated a benign testis with testicular hemorrhage and chronic vasculopathy. There was no fibrinoid necrosis of medium-size vessel walls which characterizes PAN. In this report, we review the pathogenesis, risk of contralateral testicular infarction, and management of testicular infarction.

Coexisting incarcerated femoral and obturator hernia: a case report.

BACKGROUND: Obturator hernia is a rare condition associated with a high morbidity and mortality. It is an uncommon cause of bowel obstruction most commonly described in elderly females with comorbidity. Surgical intervention is often delayed as a result of subtle presenting signs. Coexisting ipsilateral femoral hernia is an even rarer condition represented by non-exhaustive series in the literature. CASE PRESENTATION: We report a case of a healthy 36 years old lady, nulliparous, with abdominal pain and swelling in the right groin. Preoperative CT showed only a right groin hernia, that was found to be femoral at operative intervention. She recovered and was discharged from hospital but represented with further symptoms of obstruction 9 days later. Diagnostic laparoscopy demonstrated a ipsilateral obturator hernia with associated bowel infarct. The bowel was resected and the defect was repaired. DISCUSSION AND CONCLUSIONS: Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis. We describe the first case of coexisting ipsilateral femoral and obturator hernias in a young nulliparous woman with bowel obstruction. Appropriate intraoperative exploration should always be considered.