Delayed Diagnosis of Aortic Dissection: The Overlooked Clues on Chest X-Ray

Delayed Diagnosis of Aortic Dissection: The Overlooked Clues on Chest X-Ray | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed Diagnosis of Aortic Dissection: The Overlooked Clues on Chest X-Ray Yao Chen, Wenjin Wang, Lian Lin, Zhankai Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6966962/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Aug, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Acute aortic dissection (AD) is a life-threatening vascular emergency requiring immediate intervention, with mortality rates increasing by 1-2% per hour post-onset. The pathophysiology involves an intimal tear that permits blood to enter the medial layer, forming a false lumen that may expand and compromise branch vessels and end-organ perfusion. Current guidelines from the European Society of Cardiology (ESC), American College of Cardiology (ACC), and American Heart Association (AHA) highlight the necessity of risk stratification based on clinical features (e.g., tearing pain, pulse deficits), predisposing factors (e.g., hypertension), and D-dimer levels, followed by confirmatory imaging with transthoracic echocardiography (TTE) or computed tomography angiography (CTA). Despite advancements in imaging, chest radiography (CXR) remains underutilized; however, key findings—such as mediastinal widening (≥5 cm at the aortic knob), abnormal aortic contour, and displaced intimal calcifications—can offer critical diagnostic information. Case Report: A young male patient presented with acute chest pain following strenuous exertion. Initial outpatient evaluation, including complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), cardiac enzymes, and chest X-ray (CXR), yielded nondiagnostic results, leading to his discharge with analgesics. Three days later, during a national holiday when outpatient clinics were closed, the patient returned to the emergency department (ED) with persistent chest pain. A meticulous review of the initial CXR by the emergency physician revealed mediastinal widening (measuring 8.5 cm) and an abnormal contour of the aorta. Subsequent emergency computed tomography angiography (CTA) confirmed the diagnosis of a Stanford type B aortic dissection. Conclusions: This case underscores two critical learning points: (1) the diagnostic pitfalls associated with atypical early presentations of aortic dissection, and (2) the often underappreciated value of meticulous interpretation of chest X-rays in the evaluation of acute chest pain, particularly when initial studies yield unremarkable results. The three-day diagnostic delay emphasizes the necessity of maintaining a high index of suspicion for aortic dissection, even in young patients lacking classic risk factors. Acute chest pain Acute aortic dissection Chest radiography Pleuritis Differential diagnosis Figures Figure 3 Figure 4 Figure 5 Background Aortic dissection (AD) is a critical vascular emergency defined by the rupture of the aortic intima, which permits blood to infiltrate the medial layer and propagate along the vascular axis, thereby forming a dissecting hematoma that may lead to aneurysmal dilatation, referred to as aortic dissection aneurysm [ 1 ]. Clinically, AD is characterized by the acute onset of severe pain, shock, and end-organ ischemia resulting from the compression of branch vessels.[ 2 ].Acute aortic dissection (AAD) represents the most common and lethal manifestation of acute aortic syndromes, necessitating prompt diagnosis and immediate intervention. If left untreated, the mortality rate escalates by 1–2% per hour after the onset of symptoms, ultimately reaching 90% within three months [ 3 ]. International data indicate a typical age of onset between 60 and 70 years, with a notable male predominance. In contrast, the epidemiological profile of AAD in Chinese patients reveals an onset approximately 10 years earlier than that observed globally[ 4 ].Major fatal outcomes associated with AAD include aortic rupture (thoracic, abdominal, or pericardial), progressive hemorrhage (mediastinal or retroperitoneal), and end-organ failure due to malperfusion[ 5 ]. Despite advancements in diagnostics that have reduced mortality, aortic dissection remains a formidable challenge in primary care settings. Although computed tomography angiography (CTA) is regarded as the gold standard due to its sensitivity exceeding 95%, its limited availability in resource-constrained environments necessitates the exploration of alternative diagnostic approaches.[ 5 ].While chest radiography (CXR) exhibits a sensitivity of only 60%, it can provide valuable initial insights when interpreted with diligence—specifically, signs such as mediastinal widening (> 8 cm), abnormal aortic contour, displacement of calcification, and tracheal deviation. In the case presented herein, these critical radiographic indicators were unfortunately overlooked during the initial assessment, resulting in a delay in diagnosis. This underscores a significant gap in current clinical practice: the underutilization of CXR's diagnostic capabilities. Implementing systematic training to enhance recognition of these radiographic features could markedly improve early detection, particularly in settings where advanced imaging modalities are not readily accessible. This case emphasizes the necessity for heightened radiologic vigilance, even when employing "basic" imaging techniques, as accurate interpretation of CXR may yield life-saving diagnostic cues for this time-sensitive condition. Case Report An 18-year-old male presented to our general medicine clinic with persistent, moderate retrosternal chest pain occurring immediately after vigorous physical activity. The pain had a sudden onset two hours prior to presentation and was not associated with dyspnea, fever, nausea, or other systemic symptoms. Initial physical examination revealed normal vital signs, and the patient exhibited no hemodynamic instability. Diagnostic workup included a complete blood count, which yielded normal results (WBC 12.31 × 10⁹/L, Hb 151 g/dL, platelets 181 × 10⁹/L), as well as normal inflammatory markers (CRP 0.37 mg/L) and unremarkable cardiac enzyme levels (CK 125 U/L, CK-MB 9 U/L, LDH 182 U/L). Liver and renal function tests were also within normal limits, and the initial chest radiograph was interpreted as normal (Fig. 1). Given the moderate pain intensity, absence of laboratory abnormalities, and non-specific clinical presentation, the initial working diagnosis was musculoskeletal chest pain, potentially due to pleuritis or costochondritis. The patient was discharged with a three-day course of oral non-steroidal anti-inflammatory drugs (NSAIDs) and advised to monitor his symptoms. Three days after the initial presentation, the patient returned to the emergency department with persistent retrosternal chest pain characterized by moderate intensity and non-pleuritic nature, which proved unresponsive to NSAID therapy. This consultation occurred during a period of restricted outpatient access due to traditional Chinese holidays. An emergency evaluation revealed stable vital signs, symmetric blood pressures, and a normal cardiopulmonary examination. A critical reassessment of the initial chest radiograph, conducted through the hospital information system (HIS) with optimized window settings, identified previously unrecognized mediastinal widening (> 5 cm) and thoracic aortic dilation (Fig. 2). Subsequent emergency thoracic-abdominal computed tomographic angiography (CTA) confirmed a Stanford Type B aortic dissection (Fig. 3 ) in this previously healthy young adult, who exhibited no cardiovascular risk factors or family history of aortic disease. Upon confirmation of the diagnosis, the patient was promptly transferred to the emergency resuscitation unit for intensive monitoring. Intravenous esmolol (a β-blocker) was administered to maintain optimal hemodynamic parameters (heart rate < 60 bpm, systolic blood pressure 100–120 mmHg), accompanied by fentanyl analgesia via a left ventricular micropump. Following urgent consultation with the vascular surgery department, a successful thoracic endovascular aortic repair (TEVAR) was performed within 4 hours, confirming a Stanford Type B dissection without proximal extension. Subsequent comprehensive evaluation unexpectedly revealed an FBN1 mutation consistent with Marfan syndrome, accompanied by aortic root dilation measuring 45 mm. This case underscores the critical importance of systematic screening for connective tissue disorders in young patients presenting with aortic dissection and demonstrates the feasibility of endovascular management for Marfan-related Type B dissections when coordinated through multidisciplinary care. Discussion Acute aortic dissection (AD) is a highly lethal cardiovascular emergency characterized by sudden, severe tearing chest pain, necessitating prompt intervention. This case report describes an exceptionally atypical presentation of AD in a young male patient, who exhibited neither the classic symptoms—such as pulse deficits or pain migration—nor the traditional risk factors, including hypertension or a history of connective tissue disorders.Upon initial evaluation at a general internal medicine clinic, differential diagnoses including pneumothorax, pneumonia, and myocardial injury were systematically excluded through laboratory tests and chest radiography. Consequently, a plausible initial diagnosis of pleuritis or costochondritis was made, considering the patient’s age and post-exertional pain.A critical diagnostic pivot occurred during an emergency reevaluation, wherein emergency physicians adhered to the "rule-out worst-first" principle, a cornerstone of acute care medicine. This approach emphasizes the systematic exclusion of immediately life-threatening conditions, such as acute coronary syndrome, pulmonary embolism, AD, and tension pneumothorax, prior to contemplating benign etiologies.This case illustrates three crucial lessons: (1) acute aortic dissection may present atypically in younger patients without classic features; (2) "normal" initial investigations do not preclude the possibility of aortic pathology; and (3) the reinterpretation of chest radiographs, particularly with adjustments to the mediastinal window, can unearth critical findings—including mediastinal widening greater than 8 cm and abnormal aortic contour—even when initially overlooked. These insights advocate for heightened clinical vigilance and a comprehensive diagnostic approach in similar cases.This case underscores clinicians' imperative to personally review imaging beyond reports, particularly in emergencies. Key requirements include: (1) systematic analysis of all image planes/windows, focusing on high-risk areas (mediastinum/aortic contour); (2) correlating findings with clinical presentation; and (3) maintaining vigilance for life-threatening conditions. The emergency physicians' meticulous re-evaluation—adjusting window settings to identify initially missed aortic abnormalities—proved lifesaving and should become standard practice, especially for atypical presentations. We advocate: mandatory secondary image review for high-risk cases, structured acute chest pain interpretation checklists, and quality programs tracking "second-look" diagnostic yields. The axiom "no accurate diagnosis, no effective treatment" encapsulates the ethical obligation of diagnostic diligence, particularly when managing young patients with persistent symptoms or clinical-imaging discrepancies. This approach balances thoroughness with efficiency in time-sensitive settings. Despite significant advancements in medical knowledge, diagnostic challenges persist in the realm of aortic dissection (AD). Contemporary data from the International Registry of Acute Aortic Dissection (IRAD) indicate a misdiagnosis rate ranging from 14–39%, even within modern healthcare systems [ 6 ], Alarmingly, undiagnosed cases are associated with a 24-hour mortality rate as high as 50% [ 7 ]. Recent analyses from IRAD suggest that early hospital mortality remains at 59% [ 8 ], Although there has been an observed increase in incidence, this trend is likely indicative of enhanced diagnostic capabilities and improved public health awareness, rather than a genuine epidemiological shift. This apparent rise in incidence may reflect better case ascertainment owing to: (1) the widespread availability of computed tomography (CT), (2) the implementation of standardized diagnostic protocols, and (3) increased public education regarding acute chest pain. However, these statistics may still underestimate the true burden of the disease, as sudden pre-hospital deaths—particularly in younger patients—are often excluded from registry data. The persistently high mortality rates underscore the urgent need for: (1) refined risk-stratification tools, (2) enhanced education for emergency physicians regarding atypical presentations, and (3) the establishment of systems that ensure rapid access to imaging. Implementing these measures could help bridge the critical gap between diagnostic potential and clinical reality. The persistently high rates of misdiagnosis in aortic dissection (AD) can be attributed to a complex interplay of factors: (1) clinical heterogeneity, which ranges from classic presentations characterized by "tearing" pain to completely asymptomatic cases; (2) cognitive biases, including diminished clinical suspicion and premature diagnostic closure; and (3) systemic issues, such as non-standardized workflows and suboptimal utilization of diagnostic tests. Emergency departments—where approximately 70% of AD cases first present—exemplify this diagnostic challenge, as physicians often anchor their assessments on acute coronary syndrome (ACS) when faced with chest pain complaints, despite the prevalence of AD being only 1–3% within this patient population[ 9 ].While the "common-first" heuristic generally facilitates efficient decision-making, its uncritical application in the context of vascular emergencies poses significant risks. Three critical gaps have been identified: (a) an overreliance on atypical presentations to rule out AD, (b) underutilization of available imaging modalities (e.g., neglecting mediastinal assessment on initial chest X-ray), and (c) delays in specialty consultation. Addressing these issues necessitates the implementation of cognitive de-biasing training in conjunction with clinical decision support systems that incorporate the Aortic Dissection Detection Risk Score (ADD-RS) within electronic health records. Aortic dissection remains a frequently misdiagnosed condition, despite its life-threatening nature. Key strategies to address this issue include: (1) enhancing physician education regarding atypical presentations, (2) implementing standardized protocols that integrate the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer testing, and (3) ensuring rapid access to computed tomography angiography (CTA) and transesophageal echocardiography (TEE). The potential of artificial intelligence (AI) in this domain is promising; recent studies have shown that AI can achieve sensitivity rates of 89–94% in detecting subtle radiographic signs when utilized in conjunction with picture archiving and communication systems (PACS)[ 10 ].Future research should prioritize AI-assisted multi-modal analysis, incorporating electrocardiography (ECG), chest X-rays (CXR), and biomarker assessments[ 11 ]. These methodologies have the potential to enhance early detection while preserving diagnostic accuracy. This case underscores the urgent need for increased vigilance in young patients presenting with non-classical symptoms. Conclusion This case illustrates three crucial lessons: (1) acute aortic dissection may present atypically in younger patients without classic features; (2) "normal" initial investigations do not preclude the possibility of aortic pathology; and (3) the reinterpretation of chest radiographs, particularly with adjustments to the mediastinal window, can unearth critical findings—including mediastinal widening greater than 8 cm and abnormal aortic contour—even when initially overlooked. These insights advocate for heightened clinical vigilance and a comprehensive diagnostic approach in similar cases.This case underscores clinicians' imperative to personally review imaging beyond reports, particularly in emergencies. Key requirements include: (1) systematic analysis of all image planes/windows, focusing on high-risk areas (mediastinum/aortic contour); (2) correlating findings with clinical presentation; and (3) maintaining vigilance for life-threatening conditions. The emergency physicians' meticulous re-evaluation—adjusting window settings to identify initially missed aortic abnormalities—proved lifesaving and should become standard practice, especially for atypical presentations. Declarations Declaration of Figures’ Authenticity All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. Funding No funding. Availability of data and materials The data are available from the corresponding author on reasonable request. Ethical Approval This study was approved by the Ethics Committee of The First Hospital of Lanzhou University. Declarations The authors declare that they have no competing interests, and all authors agreed to publish the manuscript. Inform Consent A sentence confirming that informed consents (Consent to Participate and Consent to Publish) were obtained from all participants. Consent to Publish declaration All the authors agreed to the publication of the manuscript. References Hiratzka LF, Bakris GL, Beckman JA, ACCF/AHA/AATS/ACR/ASA/SCA/SCAI et al. /SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease.Circulation.2010;121(13):e266-369. Isselbacher EM, Preventza O, Hamilton Black J 3, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of. Aortic Disease Circulation. 2022;146(24):e334–482. Howard DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127(20):2031–7. Wang W, Duan W, Xue Y, et al. Clinical features of acute aortic dissection from the Registry of Aortic Dissection in China. J Thorac Cardiovasc Surg. 2014;148(6):2995–3000. Evangelista A, Isselbacher EM, Bossone E, et al. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation. 2018;137(17):1846–60. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903. Howard DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127(20):2031–7. Myrmel T, Larsen M, Bartnes K. The International Registry of Acute Aortic Dissections (IRAD) - experiences from the first 20 years. Scand Cardiovasc J 2016 Oct-Dec;50(5–6):329–33. Harris KM, Strauss CE, Eagle KA, et al. Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2011;124(18):1911–8. Desser TS, Sommer FG, Jeffrey RB, et al. Using Artificial Intelligence to Improve Radiology Quality and Safety. J Am Coll Radiol. 2019;16(9):1237–42. Wang W, Liu J, Zhang Y, et al. A Multi-modal Deep Learning Framework for Cardiovascular Disease Risk Prediction. J Med Syst. 2022;46(1):12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Aug, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Accepted 05 Aug, 2025 Reviews received at journal 20 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviews received at journal 16 Jul, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor assigned by journal 07 Jul, 2025 Submission checks completed at journal 07 Jul, 2025 First submitted to journal 24 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6966962","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":486966683,"identity":"5fa1d73b-396a-4bf4-8903-3247c18febf6","order_by":0,"name":"Yao Chen","email":"","orcid":"","institution":"The First Hospital of Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yao","middleName":"","lastName":"Chen","suffix":""},{"id":486966684,"identity":"89d0fa66-d073-4e2c-8a8c-f77c12f6b8af","order_by":1,"name":"Wenjin Wang","email":"","orcid":"","institution":"The First Hospital of Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Wenjin","middleName":"","lastName":"Wang","suffix":""},{"id":486966685,"identity":"028de244-ee55-409d-8729-5939eb3e2915","order_by":2,"name":"Lian Lin","email":"","orcid":"","institution":"Gansu Provincial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lian","middleName":"","lastName":"Lin","suffix":""},{"id":486966686,"identity":"6eea740c-e7f7-42e2-b75a-ee0d0b582df0","order_by":3,"name":"Zhankai Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACCQYGxgYGCTk29uaDDxIqbIjXYszPcyzZ4MGZNKK1MCTOnJFjJvmw7RBhHfKzm589nFFjwbjhRo5ZRQLbAQb+9u4EvFoY5xwzN9xwTILZ4MyzshsJPHcYJM6c3YBXC7NEgpnkAzYJNoPjydtuJEg8YzCQyMWvhU0i/Zvkg38SPAYHEswKEgwOE9bCIwH09cY2CQnJjhQzhoQEIrRISOSUSc7skzAABbJEwoE0HoJ+kZ+Rvk2y51tdfRswKj/+/Gcjx9/ei18LpktJUz4KRsEoGAWjACsAAIhHSsoM0j92AAAAAElFTkSuQmCC","orcid":"","institution":"The First Hospital of Lanzhou University","correspondingAuthor":true,"prefix":"","firstName":"Zhankai","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-06-24 14:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6966962/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6966962/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-025-00971-8","type":"published","date":"2025-08-27T15:57:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87271074,"identity":"c3a51153-28fa-456f-80a1-a417719b237f","added_by":"auto","created_at":"2025-07-22 08:23:24","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":151023,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6966962/v1/9b95196f786d061ad93dfb89.jpeg"},{"id":87269499,"identity":"2a75adb3-a9cc-4bce-83a6-eea9c18d0ca0","added_by":"auto","created_at":"2025-07-22 08:15:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":390107,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6966962/v1/33be4b51848a93a61f94506d.png"},{"id":87271072,"identity":"fb338eda-0fda-4188-a5d2-54506f4b8736","added_by":"auto","created_at":"2025-07-22 08:23:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":243819,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6966962/v1/3c81561aff2ac206b6a3c4b7.png"},{"id":90344904,"identity":"4f78de75-998e-43c3-be44-eda52b2997bb","added_by":"auto","created_at":"2025-09-01 16:07:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1381069,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6966962/v1/dd01733a-28b8-4427-b421-b8873ea22c2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delayed Diagnosis of Aortic Dissection: The Overlooked Clues on Chest X-Ray","fulltext":[{"header":"Background","content":"\u003cp\u003eAortic dissection (AD) is a critical vascular emergency defined by the rupture of the aortic intima, which permits blood to infiltrate the medial layer and propagate along the vascular axis, thereby forming a dissecting hematoma that may lead to aneurysmal dilatation, referred to as aortic dissection aneurysm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Clinically, AD is characterized by the acute onset of severe pain, shock, and end-organ ischemia resulting from the compression of branch vessels.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Acute aortic dissection (AAD) represents the most common and lethal manifestation of acute aortic syndromes, necessitating prompt diagnosis and immediate intervention. If left untreated, the mortality rate escalates by 1–2% per hour after the onset of symptoms, ultimately reaching 90% within three months [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. International data indicate a typical age of onset between 60 and 70 years, with a notable male predominance. In contrast, the epidemiological profile of AAD in Chinese patients reveals an onset approximately 10 years earlier than that observed globally[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].Major fatal outcomes associated with AAD include aortic rupture (thoracic, abdominal, or pericardial), progressive hemorrhage (mediastinal or retroperitoneal), and end-organ failure due to malperfusion[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite advancements in diagnostics that have reduced mortality, aortic dissection remains a formidable challenge in primary care settings. Although computed tomography angiography (CTA) is regarded as the gold standard due to its sensitivity exceeding 95%, its limited availability in resource-constrained environments necessitates the exploration of alternative diagnostic approaches.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].While chest radiography (CXR) exhibits a sensitivity of only 60%, it can provide valuable initial insights when interpreted with diligence—specifically, signs such as mediastinal widening (\u0026gt; 8 cm), abnormal aortic contour, displacement of calcification, and tracheal deviation. In the case presented herein, these critical radiographic indicators were unfortunately overlooked during the initial assessment, resulting in a delay in diagnosis. This underscores a significant gap in current clinical practice: the underutilization of CXR's diagnostic capabilities. Implementing systematic training to enhance recognition of these radiographic features could markedly improve early detection, particularly in settings where advanced imaging modalities are not readily accessible. This case emphasizes the necessity for heightened radiologic vigilance, even when employing \"basic\" imaging techniques, as accurate interpretation of CXR may yield life-saving diagnostic cues for this time-sensitive condition.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eAn 18-year-old male presented to our general medicine clinic with persistent, moderate retrosternal chest pain occurring immediately after vigorous physical activity. The pain had a sudden onset two hours prior to presentation and was not associated with dyspnea, fever, nausea, or other systemic symptoms. Initial physical examination revealed normal vital signs, and the patient exhibited no hemodynamic instability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiagnostic workup included a complete blood count, which yielded normal results (WBC 12.31 \u0026times; 10⁹/L, Hb 151 g/dL, platelets 181 \u0026times; 10⁹/L), as well as normal inflammatory markers (CRP 0.37 mg/L) and unremarkable cardiac enzyme levels (CK 125 U/L, CK-MB 9 U/L, LDH 182 U/L). Liver and renal function tests were also within normal limits, and the initial chest radiograph was interpreted as normal (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003eGiven the moderate pain intensity, absence of laboratory abnormalities, and non-specific clinical presentation, the initial working diagnosis was musculoskeletal chest pain, potentially due to pleuritis or costochondritis. The patient was discharged with a three-day course of oral non-steroidal anti-inflammatory drugs (NSAIDs) and advised to monitor his symptoms.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree days after the initial presentation, the patient returned to the emergency department with persistent retrosternal chest pain characterized by moderate intensity and non-pleuritic nature, which proved unresponsive to NSAID therapy. This consultation occurred during a period of restricted outpatient access due to traditional Chinese holidays. An emergency evaluation revealed stable vital signs, symmetric blood pressures, and a normal cardiopulmonary examination. A critical reassessment of the initial chest radiograph, conducted through the hospital information system (HIS) with optimized window settings, identified previously unrecognized mediastinal widening (\u0026gt;\u0026thinsp;5 cm) and thoracic aortic dilation (Fig.\u0026nbsp;2). Subsequent emergency thoracic-abdominal computed tomographic angiography (CTA) confirmed a Stanford Type B aortic dissection (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) in this previously healthy young adult, who exhibited no cardiovascular risk factors or family history of aortic disease.\u003c/p\u003e\n\u003cp\u003eUpon confirmation of the diagnosis, the patient was promptly transferred to the emergency resuscitation unit for intensive monitoring. Intravenous esmolol (a \u0026beta;-blocker) was administered to maintain optimal hemodynamic parameters (heart rate\u0026thinsp;\u0026lt;\u0026thinsp;60 bpm, systolic blood pressure 100\u0026ndash;120 mmHg), accompanied by fentanyl analgesia via a left ventricular micropump. Following urgent consultation with the vascular surgery department, a successful thoracic endovascular aortic repair (TEVAR) was performed within 4 hours, confirming a Stanford Type B dissection without proximal extension. Subsequent comprehensive evaluation unexpectedly revealed an FBN1 mutation consistent with Marfan syndrome, accompanied by aortic root dilation measuring 45 mm. This case underscores the critical importance of systematic screening for connective tissue disorders in young patients presenting with aortic dissection and demonstrates the feasibility of endovascular management for Marfan-related Type B dissections when coordinated through multidisciplinary care.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcute aortic dissection (AD) is a highly lethal cardiovascular emergency characterized by sudden, severe tearing chest pain, necessitating prompt intervention. This case report describes an exceptionally atypical presentation of AD in a young male patient, who exhibited neither the classic symptoms\u0026mdash;such as pulse deficits or pain migration\u0026mdash;nor the traditional risk factors, including hypertension or a history of connective tissue disorders.Upon initial evaluation at a general internal medicine clinic, differential diagnoses including pneumothorax, pneumonia, and myocardial injury were systematically excluded through laboratory tests and chest radiography. Consequently, a plausible initial diagnosis of pleuritis or costochondritis was made, considering the patient\u0026rsquo;s age and post-exertional pain.A critical diagnostic pivot occurred during an emergency reevaluation, wherein emergency physicians adhered to the \"rule-out worst-first\" principle, a cornerstone of acute care medicine. This approach emphasizes the systematic exclusion of immediately life-threatening conditions, such as acute coronary syndrome, pulmonary embolism, AD, and tension pneumothorax, prior to contemplating benign etiologies.This case illustrates three crucial lessons: (1) acute aortic dissection may present atypically in younger patients without classic features; (2) \"normal\" initial investigations do not preclude the possibility of aortic pathology; and (3) the reinterpretation of chest radiographs, particularly with adjustments to the mediastinal window, can unearth critical findings\u0026mdash;including mediastinal widening greater than 8 cm and abnormal aortic contour\u0026mdash;even when initially overlooked. These insights advocate for heightened clinical vigilance and a comprehensive diagnostic approach in similar cases.This case underscores clinicians' imperative to personally review imaging beyond reports, particularly in emergencies. Key requirements include: (1) systematic analysis of all image planes/windows, focusing on high-risk areas (mediastinum/aortic contour); (2) correlating findings with clinical presentation; and (3) maintaining vigilance for life-threatening conditions. The emergency physicians' meticulous re-evaluation\u0026mdash;adjusting window settings to identify initially missed aortic abnormalities\u0026mdash;proved lifesaving and should become standard practice, especially for atypical presentations. We advocate: mandatory secondary image review for high-risk cases, structured acute chest pain interpretation checklists, and quality programs tracking \"second-look\" diagnostic yields. The axiom \"no accurate diagnosis, no effective treatment\" encapsulates the ethical obligation of diagnostic diligence, particularly when managing young patients with persistent symptoms or clinical-imaging discrepancies. This approach balances thoroughness with efficiency in time-sensitive settings.\u003c/p\u003e\u003cp\u003eDespite significant advancements in medical knowledge, diagnostic challenges persist in the realm of aortic dissection (AD). Contemporary data from the International Registry of Acute Aortic Dissection (IRAD) indicate a misdiagnosis rate ranging from 14\u0026ndash;39%, even within modern healthcare systems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], Alarmingly, undiagnosed cases are associated with a 24-hour mortality rate as high as 50% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Recent analyses from IRAD suggest that early hospital mortality remains at 59% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], Although there has been an observed increase in incidence, this trend is likely indicative of enhanced diagnostic capabilities and improved public health awareness, rather than a genuine epidemiological shift. This apparent rise in incidence may reflect better case ascertainment owing to: (1) the widespread availability of computed tomography (CT), (2) the implementation of standardized diagnostic protocols, and (3) increased public education regarding acute chest pain. However, these statistics may still underestimate the true burden of the disease, as sudden pre-hospital deaths\u0026mdash;particularly in younger patients\u0026mdash;are often excluded from registry data. The persistently high mortality rates underscore the urgent need for: (1) refined risk-stratification tools, (2) enhanced education for emergency physicians regarding atypical presentations, and (3) the establishment of systems that ensure rapid access to imaging. Implementing these measures could help bridge the critical gap between diagnostic potential and clinical reality.\u003c/p\u003e\u003cp\u003eThe persistently high rates of misdiagnosis in aortic dissection (AD) can be attributed to a complex interplay of factors: (1) clinical heterogeneity, which ranges from classic presentations characterized by \"tearing\" pain to completely asymptomatic cases; (2) cognitive biases, including diminished clinical suspicion and premature diagnostic closure; and (3) systemic issues, such as non-standardized workflows and suboptimal utilization of diagnostic tests. Emergency departments\u0026mdash;where approximately 70% of AD cases first present\u0026mdash;exemplify this diagnostic challenge, as physicians often anchor their assessments on acute coronary syndrome (ACS) when faced with chest pain complaints, despite the prevalence of AD being only 1\u0026ndash;3% within this patient population[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].While the \"common-first\" heuristic generally facilitates efficient decision-making, its uncritical application in the context of vascular emergencies poses significant risks. Three critical gaps have been identified: (a) an overreliance on atypical presentations to rule out AD, (b) underutilization of available imaging modalities (e.g., neglecting mediastinal assessment on initial chest X-ray), and (c) delays in specialty consultation. Addressing these issues necessitates the implementation of cognitive de-biasing training in conjunction with clinical decision support systems that incorporate the Aortic Dissection Detection Risk Score (ADD-RS) within electronic health records.\u003c/p\u003e\u003cp\u003eAortic dissection remains a frequently misdiagnosed condition, despite its life-threatening nature. Key strategies to address this issue include: (1) enhancing physician education regarding atypical presentations, (2) implementing standardized protocols that integrate the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer testing, and (3) ensuring rapid access to computed tomography angiography (CTA) and transesophageal echocardiography (TEE). The potential of artificial intelligence (AI) in this domain is promising; recent studies have shown that AI can achieve sensitivity rates of 89\u0026ndash;94% in detecting subtle radiographic signs when utilized in conjunction with picture archiving and communication systems (PACS)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].Future research should prioritize AI-assisted multi-modal analysis, incorporating electrocardiography (ECG), chest X-rays (CXR), and biomarker assessments[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These methodologies have the potential to enhance early detection while preserving diagnostic accuracy. This case underscores the urgent need for increased vigilance in young patients presenting with non-classical symptoms.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case illustrates three crucial lessons: (1) acute aortic dissection may present atypically in younger patients without classic features; (2) \"normal\" initial investigations do not preclude the possibility of aortic pathology; and (3) the reinterpretation of chest radiographs, particularly with adjustments to the mediastinal window, can unearth critical findings\u0026mdash;including mediastinal widening greater than 8 cm and abnormal aortic contour\u0026mdash;even when initially overlooked. These insights advocate for heightened clinical vigilance and a comprehensive diagnostic approach in similar cases.This case underscores clinicians' imperative to personally review imaging beyond reports, particularly in emergencies. Key requirements include: (1) systematic analysis of all image planes/windows, focusing on high-risk areas (mediastinum/aortic contour); (2) correlating findings with clinical presentation; and (3) maintaining vigilance for life-threatening conditions. The emergency physicians' meticulous re-evaluation\u0026mdash;adjusting window settings to identify initially missed aortic abnormalities\u0026mdash;proved lifesaving and should become standard practice, especially for atypical presentations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Figures’ Authenticity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of The First Hospital of Lanzhou University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests, and all authors agreed to publish the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInform Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA sentence confirming that informed consents (Consent to Participate and Consent to Publish) were obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors agreed to the publication of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHiratzka LF, Bakris GL, Beckman JA, ACCF/AHA/AATS/ACR/ASA/SCA/SCAI et al. /SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease.Circulation.2010;121(13):e266-369.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsselbacher EM, Preventza O, Hamilton Black J 3, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of. Aortic Disease Circulation. 2022;146(24):e334\u0026ndash;482.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoward DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127(20):2031\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang W, Duan W, Xue Y, et al. Clinical features of acute aortic dissection from the Registry of Aortic Dissection in China. J Thorac Cardiovasc Surg. 2014;148(6):2995\u0026ndash;3000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvangelista A, Isselbacher EM, Bossone E, et al. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation. 2018;137(17):1846\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoward DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127(20):2031\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMyrmel T, Larsen M, Bartnes K. The International Registry of Acute Aortic Dissections (IRAD) - experiences from the first 20 years. Scand Cardiovasc J 2016 Oct-Dec;50(5\u0026ndash;6):329\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarris KM, Strauss CE, Eagle KA, et al. Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2011;124(18):1911\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDesser TS, Sommer FG, Jeffrey RB, et al. Using Artificial Intelligence to Improve Radiology Quality and Safety. J Am Coll Radiol. 2019;16(9):1237\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang W, Liu J, Zhang Y, et al. A Multi-modal Deep Learning Framework for Cardiovascular Disease Risk Prediction. J Med Syst. 2022;46(1):12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute chest pain, Acute aortic dissection, Chest radiography, Pleuritis, Differential diagnosis","lastPublishedDoi":"10.21203/rs.3.rs-6966962/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6966962/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nAcute aortic dissection (AD) is a life-threatening vascular emergency requiring immediate intervention, with mortality rates increasing by 1-2% per hour post-onset. The pathophysiology involves an intimal tear that permits blood to enter the medial layer, forming a false lumen that may expand and compromise branch vessels and end-organ perfusion. Current guidelines from the European Society of Cardiology (ESC), American College of Cardiology (ACC), and American Heart Association (AHA) highlight the necessity of risk stratification based on clinical features (e.g., tearing pain, pulse deficits), predisposing factors (e.g., hypertension), and D-dimer levels, followed by confirmatory imaging with transthoracic echocardiography (TTE) or computed tomography angiography (CTA). Despite advancements in imaging, chest radiography (CXR) remains underutilized; however, key findings—such as mediastinal widening (≥5 cm at the aortic knob), abnormal aortic contour, and displaced intimal calcifications—can offer critical diagnostic information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Report:\u003c/strong\u003e\u003cbr\u003e\nA young male patient presented with acute chest pain following strenuous exertion. Initial outpatient evaluation, including complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), cardiac enzymes, and chest X-ray (CXR), yielded nondiagnostic results, leading to his discharge with analgesics. Three days later, during a national holiday when outpatient clinics were closed, the patient returned to the emergency department (ED) with persistent chest pain. A meticulous review of the initial CXR by the emergency physician revealed mediastinal widening (measuring 8.5 cm) and an abnormal contour of the aorta. Subsequent emergency computed tomography angiography (CTA) confirmed the diagnosis of a Stanford type B aortic dissection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case underscores two critical learning points: (1) the diagnostic pitfalls associated with atypical early presentations of aortic dissection, and (2) the often underappreciated value of meticulous interpretation of chest X-rays in the evaluation of acute chest pain, particularly when initial studies yield unremarkable results. The three-day diagnostic delay emphasizes the necessity of maintaining a high index of suspicion for aortic dissection, even in young patients lacking classic risk factors.\u003c/p\u003e","manuscriptTitle":"Delayed Diagnosis of Aortic Dissection: The Overlooked Clues on Chest X-Ray","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 08:15:20","doi":"10.21203/rs.3.rs-6966962/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-08-06T01:42:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T13:00:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59304939052677438763741709975575289040","date":"2025-07-17T14:40:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T01:37:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65884210559451375907226541719960304801","date":"2025-07-17T00:39:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T23:29:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-07T05:00:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-07T04:58:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-06-24T14:38:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"603eb300-0017-4b1b-b66c-66ebe3742884","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:01:27+00:00","versionOfRecord":{"articleIdentity":"rs-6966962","link":"https://doi.org/10.1186/s12245-025-00971-8","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2025-08-27 15:57:36","publishedOnDateReadable":"August 27th, 2025"},"versionCreatedAt":"2025-07-22 08:15:20","video":"","vorDoi":"10.1186/s12245-025-00971-8","vorDoiUrl":"https://doi.org/10.1186/s12245-025-00971-8","workflowStages":[]},"version":"v1","identity":"rs-6966962","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6966962","identity":"rs-6966962","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}