A catastrophic confluence: Concurrent subarachnoid haemorrhage and acute mesenteric ischaemia

Abstract Background Acute mesenteric ischaemia (AMI) and subarachnoid haemorrhage (SAH) are life‐threatening emergencies with diametrically opposed treatment requirements regarding anticoagulation. This report describes a rare, complex case where both conditions occurred simultaneously, creating a significant therapeutic dilemma. Case presentation A 64‐year‐old male with chronic atrial fibrillation presented with severe abdominal pain and vomiting. Diagnostic imaging confirmed AMI involving the superior mesenteric artery (SMA), along with splenic and renal infarcts. Concurrent brain imaging revealed an acute, nonaneurysmal SAH. The necessity of anticoagulation for AMI was directly contraindicated by the risk of catastrophic intracranial rebleeding. Management A multidisciplinary team adopted a staged, surgical‐first approach. The patient underwent a damage‐control laparotomy, resulting in the resection of 480 cm of necrotic small bowel and the creation of a double‐barrel ileostomy. Following neurological stabilization and serial imaging, anticoagulation was cautiously resumed on postoperative day six. Despite resulting in short gut syndrome, the patient achieved a satisfactory outcome. Conclusion This case illustrates that survival in mutually exclusive clinical emergencies is achievable through individualized, pragmatic multidisciplinary decision‐making. Prioritizing the immediate septic threat of bowel necrosis while delaying anticoagulation under close neurological surveillance can lead to favourable outcomes in high‐risk presentations.