Stanford Type B Aortic Dissection Presenting as a Massive Hemothorax: A Case Report

Stanford Type B Aortic Dissection Presenting as a Massive Hemothorax: A Case Report | 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 Stanford Type B Aortic Dissection Presenting as a Massive Hemothorax: A Case Report Muhammad Moin Ud Din Arshad, Rimsha Maqsood, Mesum Abbas, Ali Sher, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8214584/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Stanford Type B aortic dissection (TBAD) is a critical vascular emergency typically presenting with acute tearing chest or back pain. While pleural effusions are common in TBAD, presentation as a massive hemothorax is a rare and life-threatening complication that often signals aortic rupture, traditionally necessitating urgent surgical or endovascular intervention. Case Presentation: We report the case of a 40-year-old female with a ten-year history of hypertension who presented with severe chest pain, diaphoresis, and dyspnea. Physical examination revealed signs of massive left-sided pleural effusion, and laboratory evaluation demonstrated severe anemia and acute kidney injury. Computed Tomography (CT) angiography confirmed a Stanford Type B aortic dissection extending from the left subclavian artery to the inferior mesenteric artery, complicated by a massive left hydropneumothorax. Crucially, the celiac trunk, superior mesenteric artery, and renal arteries originated from the true lumen, preserving end-organ perfusion. Management and Outcome: Despite the presence of hemothorax, the patient was hemodynamically responsive to resuscitation. A left intercostal chest tube was placed, draining hemorrhagic fluid. She was managed conservatively with aggressive anti-impulse therapy (strict blood pressure control). The patient stabilized rapidly without the need for Thoracic Endovascular Aortic Repair (TEVAR), renal function normalized, and she was discharged on the seventh day. Conclusion: This case illustrates that while hemothorax in the setting of Type B aortic dissection is a red flag for rupture, it does not universally mandate surgical repair. In hemodynamically stable patients with preserved visceral perfusion, a conservative approach comprising tube thoracostomy and strict blood pressure control can yield successful outcomes. Stanford Type B Aortic Dissection Hemothorax Anti-impulse therapy Conservative management Case Report Figures Figure 1 Figure 2 Figure 3 Figure 4 Highlights A rare presentation of Stanford Type B aortic dissection manifesting as a massive left hemothorax and hydropneumothorax. Pleural fluid analysis with very high LDH and low glucose indicated hemorrhagic exudate associated with the aortic event. Despite initial instability, end-organ perfusion was preserved through the true lumen on CT angiography. Conservative management with strict blood pressure control achieved stabilization without the need for TEVAR. Rapid clinical improvement allowed chest tube removal and discharge by day seven. Introduction Acute aortic dissection (AAD) is a catastrophic vascular emergency characterized by the separation of the aortic wall layers, creating a false lumen that may compromise end-organ perfusion or rupture. Based on the Stanford classification, dissections involving the ascending aorta are classified as Type A, requiring immediate surgical intervention, while those limited to the descending aorta are classified as Type B [ 1 ]. While systemic hypertension is the most significant risk factor for AAD, the clinical presentation is often variable, ranging from classic tearing chest pain to syncope or neurological deficits. Hemothorax is a rare but lethal complication of AAD, typically signifying a rupture of the descending thoracic aorta into the pleural space. Spontaneous hemothorax is most frequently associated with malignancy or pneumothorax; however, vascular etiologies like aortic dissection account for a small but critical subset of cases [ 2 ]. Although massive hemothorax in the context of Type B aortic dissection (TBAD) often necessitates urgent thoracic endovascular aortic repair (TEVAR) or open surgery, select cases may stabilize with aggressive medical management if the rupture is contained [ 3 ]. We present a case of a 40-year-old female with a history of hypertension who presented with a massive left-sided hemothorax secondary to a Stanford Type B aortic dissection. This case highlights the diagnostic challenge of aortic dissection presenting primarily with pleural manifestations and demonstrates the successful outcome of conservative management in a patient with preserved end-organ perfusion. The manuscript has been prepared according to the TITAN checklist [ 11 ] and the CARE checklist [ 12 ] Case Presentation A 40-year-old woman presented to the emergency department with the sudden onset of severe chest pain radiating to the back, accompanied by diaphoresis and a positional dry cough that prevented her from lying supine. She had a 10-year history of hypertension and long-standing joint pain previously labeled as rheumatoid arthritis, though she had received only symptomatic therapy. Recent spinal imaging provided context for her chronic pain, revealing a reversal of cervical lordosis with prominent osteophyte complexes at C4–C5 and C5–C6 causing canal stenosis, alongside degenerative disc disease at L3–L4 and L4–L5. On arrival, the patient appeared visibly distressed. Her vital signs demonstrated hypertensive urgency with a blood pressure of 180/90 mmHg, tachycardia (pulse 110/min), tachypnea (respiratory rate 29/min), and hypoxia (oxygen saturation 91% on room air). Complete Arterial blood Gas Analysis was done, which is given in Table 1 . Respiratory examination revealed markedly decreased breath sounds over the left hemithorax, with stony dullness and reduced vocal fremitus, while the cardiovascular examination was otherwise unremarkable. Electrocardiography showed sinus tachycardia with new ST-segment depressions in the anterior leads. Cardiac biomarkers were elevated, with a high-sensitivity Troponin-I of 120.84 pg/mL (reference <27 pg/mL), suggestive of myocardial strain secondary to the acute aortic event. Detailed laboratory evaluation was performed to assess systemic involvement. Hematologic testing revealed severe normocytic anemia with a hemoglobin of 7.4 g/dL and an MCV of 84 fl, alongside reactive thrombocytosis (platelet count 502 × 10⁹/L) and a normal total leukocyte count of 8.5 × 10⁹/L, though mild lymphopenia (17%) was noted (Table 2) . Biochemical profiling on admission demonstrated mild acute kidney injury, with a urea of 36 mg/dL and creatinine of 1.40 mg/dL. Electrolyte analysis revealed significant hypokalemia (2.01 mEq/L) with normal sodium levels (135.9 mEq/L). Liver function tests were largely preserved (Total Bilirubin 0.54 mg/dL, ALT 35.9 U/L), although Alkaline Phosphatase was transiently elevated at 154 U/L. To clarify the etiology of her joint pain, autoimmune serology was performed; both Rheumatoid Factor (<20.0 IU/mL) and Anti-CCP (<0.5 U/mL) were negative, suggesting seronegative arthritis or degenerative joint disease rather than active rheumatoid arthritis (Table 3). Chest radiography demonstrated complete opacification of the left hemithorax consistent with a large hemothorax (Figures 1, 2, and 4) . CT angiography confirmed a Stanford Type B aortic dissection. The dissection originated just distal to the left subclavian artery and extended to the inferior mesenteric artery. The true and false lumens were clearly delineated, with the celiac trunk, superior mesenteric artery, and both renal arteries arising from the true lumen. A loculated left hydropneumothorax with internal septations and air–fluid levels was also visualized (Figure 3). A left intercostal chest tube was inserted, draining hemorrhagic pleural fluid. Analysis of the fluid revealed a grossly hemorrhagic exudate (RBC 3007/µL, hemolysis index 12818) with a protein level >17.2 g/dL and markedly elevated LDH (>4395 U/L). Glucose was critically low (<25 mg/dL). Microbiology and cytology returned negative for organisms and malignant cells, ruling out empyema and malignancy (Table 4). Following multidisciplinary evaluation, conservative management was selected as there was no evidence of frank rupture or end-organ malperfusion. Blood pressure control was achieved with oral bisoprolol and valsartan. With hemodynamic stabilization and rehydration, her renal function normalized (creatinine improved to 0.69 mg/dL and urea to 22 mg/dL) and alkaline phosphatase levels returned to normal range (67 U/L). The chest tube was removed after drainage subsided and lung re-expansion was confirmed. By day 7, the patient was hemodynamically stable, chest-tube free, and maintaining oxygen saturation on room air. She was discharged on antihypertensives with strict blood pressure monitoring and scheduled outpatient CT follow-up. A table showing the complete chronological sequence of events is given in Table 5. Discussion Stanford Type B aortic dissection (TBAD) accounts for approximately one-third of all aortic dissections. The classic presentation involves sudden, severe back or chest pain; however, the clinical picture can be obscured by complications such as pleural effusion or hemothorax [ 4 ]. In this patient, the presence of a massive hemothorax initially raised concerns for a primary pleuropulmonary pathology or malignancy, but the acute onset of pain and hypertensive urgency pointed toward a vascular etiology. The mechanism of hemothorax in AAD typically involves the transudation of fluid across the thin wall of the false lumen or a frank rupture into the pleural cavity [ 5 ]. While left-sided hemothorax is more common due to the anatomical proximity of the descending aorta to the left pleural space, right-sided presentations have also been documented [ 1 , 6 ]. In our case, the fluid analysis revealed a hemorrhagic exudate with high lactate dehydrogenase (LDH) and low glucose, consistent with the localized metabolic derangement caused by the breakdown of blood in the pleural space. The management of TBAD is dictated by the presence of complications. Uncomplicated TBAD is generally managed medically with strict blood pressure control (anti-impulse therapy). Conversely, complicated TBAD—defined by rupture, malperfusion, or refractory pain—often requires intervention, such as TEVAR [ 7 ]. A ruptured AAD presenting with hemothorax is traditionally an indication for urgent repair to prevent exsanguination [ 3 , 8 ]. However, in this unique case, CT angiography demonstrated that the visceral arteries (celiac, SMA, and renal) originated from the true lumen, ensuring end-organ perfusion. Furthermore, the patient stabilized hemodynamically after initial tube thoracostomy and aggressive antihypertensive therapy. Recent literature suggests that extrapleural hematomas or contained ruptures in TBAD can sometimes be managed conservatively if the patient remains stable [ 9 , 10 ]. This aligns with our approach, where the absence of active contrast extravasation on repeat imaging and the cessation of pleural output allowed for a non-surgical resolution. This case emphasizes that while hemothorax in TBAD is a surgical emergency red flag, careful selection of patients for conservative management is possible when hemodynamic stability is achieved and end-organ perfusion is preserved. Conclusion Stanford Type B aortic dissection presenting as a massive hemothorax is a high-risk clinical entity that requires a high index of suspicion, particularly in hypertensive patients with atypical chest symptoms. While hemothorax often signals frank rupture necessitating urgent TEVAR or surgical intervention, this case highlights that immediate invasive repair is not invariably required. Conservative management, characterized by strict anti-impulse therapy and close hemodynamic monitoring, can be a safe and effective strategy in select patients where end-organ perfusion is preserved via the true lumen. Clinicians should prioritize rapid CT angiography to delineate the dissection anatomy, allowing for a tailored therapeutic approach that balances the risks of intervention against the potential for medical stabilization. Declarations Funding Statement: This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of competing interests: The authors declare that they have no competing interests. Declaration of AI Use: Artificial intelligence (AI) tools, including ChatGPT, were used in drafting and editing portions of this manuscript. The final content was reviewed and approved by the authors to ensure accuracy and integrity. Ethical Approval: Written informed consent was obtained from the patient. The patient gave written and informed consent, which can be provided on demand. Clinical Trial Registration: Not applicable, this is not a clinical trial. Consent for publication Written informed consent for publication of clinical details/images was obtained from the patient. Availability of data and materials All data generated or analysed during this case report are included within this published article. Acknowledgements NA Author Contributions Muhammad Moin Ud Din Arshad Conceptualization; Data curation; Investigation; Writing – original draft; Visualization; Project administration. Rimsha Maqsood Investigation; Data curation; Clinical management of the patient; Writing – review & editing. Mesum Abbas Formal analysis; Resources; Writing – review & editing. Ali Sher Data curation; Acquisition of clinical and imaging data; Validation. Abdul Hannan Asghar Methodology; Literature review; Writing – review & editing. Muhammad Bilal Akram Supervision; Clinical oversight; Critical revision of the manuscript. Muhammad Abdullah Masood Data interpretation; Radiology input; Verification of imaging findings; Writing – review & editing. Amit Kumar Thakur Overall supervision; Final manuscript approval; Corresponding author responsibilities; Critical review and editing. References Ozkan F, Akpinar E, Serter T, Ozyüksel A, Hazirolan T. Ruptured type B aortic dissection presenting with right hemothorax. Diagn Interv Radiol. 2008 Mar;14(1):6-8. PMID: 18306137. Patrini D, Panagiotopoulos N, Pararajasingham J, Gvinianidze L, Iqbal Y, Lawrence DR. Etiology and management of spontaneous haemothorax. J Thorac Dis. 2015 Mar;7(3):520-6. doi: 10.3978/j.issn.2072-1439.2014.12.50. PMID: 25922734; PMCID: PMC4387396. Abdallah, F. , Gharsalli, H. , Kwas, H. , Taktak, S. , Chtourou, A. and Kheder, A. (2013) Hemothorax Revealing Aortic Aneurism and Aortic Dissection. Open Journal of Respiratory Diseases , 3, 113-115. doi: 10.4236/ojrd.2013.33017. Slind RO, Rodarte JR. Selected reports. Spontaneous hemothorax in an otherwise healthy young man. Chest. 1974 Jul;66(1):81. doi: 10.1378/chest.66.1.81. PMID: 4843606. Song P, Bachman A, Kelly L. Late Diagnosis of a Large Extrapleural Hematoma in a Patient With Stanford Type B Aortic Dissection: A Case Report and Review of Literature. J Cardiothorac Vasc Anesth. 2022 Apr;36(4):1118-1122. doi: 10.1053/j.jvca.2021.01.010. Epub 2021 Jan 12. PMID: 33549486. Chang, Jui-Tsung & Lin, Yi-Chang. (2019). Acute Type B aortic dissection with right hemothorax. Journal of Medical Sciences. 39. 10.4103/jmedsci.jmedsci_136_18. Takago S, Nishida S, Noda Y, Nosaka Y, Yamamoto T. Thoracic endovascular aortic repair of a ruptured acute type B aortic dissection presenting with right hemothorax: a case report and review of the literature. Gen Thorac Cardiovasc Surg. 2021 Oct;69(10):1438-1443. doi: 10.1007/s11748-021-01678-2. Epub 2021 Jun 30. PMID: 34195926. Liu, B., Ma, D., Bai, Y. et al. Large extrapleural hematoma in a patient with Stanford type B acute aortic dissection: a case report. J Med Case Reports 19, 348 (2025). https://doi.org/10.1186/s13256-025-05400-1 Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, Tolva V, Deeb MG, Upchurch GR Jr, Cooper JV, Fang J, Isselbacher EM, Sundt TM 3rd, Eagle KA; IRAD Investigators. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006 Jul 4;114(1 Suppl):I357-64. doi: 10.1161/CIRCULATIONAHA.105.000620. PMID: 16820600. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015 Feb 28;385(9970):800-11. doi: 10.1016/S0140-6736(14)61005-9. Epub 2015 Feb 6. PMID: 25662791. Kerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA. Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier Journal of Science 2025:10;100079. Riley DS, Barber MS, Kienle GS, AronsonJK, et al. CARE guidelines for case reports: explanation and elaboration document. JClinEpi 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026. Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files TableFile.docx Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8214584","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":556419671,"identity":"fd166899-a998-47a1-9cf6-574611fab748","order_by":0,"name":"Muhammad Moin Ud Din Arshad","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Moin Ud Din","lastName":"Arshad","suffix":""},{"id":556419672,"identity":"4ecae994-2e60-433f-8f38-38186d28b65f","order_by":1,"name":"Rimsha Maqsood","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Rimsha","middleName":"","lastName":"Maqsood","suffix":""},{"id":556419673,"identity":"cc16bb33-f835-4ba9-b6ab-84a140d0e4d1","order_by":2,"name":"Mesum Abbas","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Mesum","middleName":"","lastName":"Abbas","suffix":""},{"id":556419674,"identity":"d0a608c4-d3a5-4560-93cb-a084ded7f338","order_by":3,"name":"Ali Sher","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Sher","suffix":""},{"id":556419676,"identity":"c0cc151d-08b5-4c7c-baa0-34f2a776568c","order_by":4,"name":"Abdul Hannan Asghar","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Abdul","middleName":"Hannan","lastName":"Asghar","suffix":""},{"id":556419681,"identity":"99781b51-935b-494a-aa20-02e5682acec2","order_by":5,"name":"Muhammad Bilal Akram","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Bilal","lastName":"Akram","suffix":""},{"id":556419682,"identity":"0b89121a-afe5-4437-9d0b-e183e718314c","order_by":6,"name":"Muhammad Abdullah Masood","email":"","orcid":"","institution":"Quaid-e-Azam Medical College","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Abdullah","lastName":"Masood","suffix":""},{"id":556419683,"identity":"4cf29dd1-3239-4f8d-9ed3-e7758928e22b","order_by":7,"name":"Amit Kumar Thakur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDCCA0CcAIRg8AGI2diJ0pIA1sLYOAOkhZkYLQxQLc08IIqQFr7bh59uePgjLXFt+9nnj21+bZPnY2Zg/PAxB7cWyXNpZjcSEnISt51JN2zO7btt2MbMwCw5cxtuLQZnGEBaKhK3HUhjbM7tuc0I1MLGzItXC/s3iJbzzxibLXtu2xOhhQfqsBtAWxh+3E4kqEXyDE/ZjYS0NONtN54xzuxtuJ3cxszYjNcvfGfYt938YZMsu+18GsOHH39u285vbz744SMeLaiAsQ1MNhCrHgT+kKJ4FIyCUTAKRgoAADyQWgSzrKChAAAAAElFTkSuQmCC","orcid":"","institution":"Shukraraj Tropical and Infectious Disease Hospital","correspondingAuthor":true,"prefix":"","firstName":"Amit","middleName":"Kumar","lastName":"Thakur","suffix":""}],"badges":[],"createdAt":"2025-11-26 15:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8214584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8214584/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98022813,"identity":"1b88516e-d091-4350-9a9b-38c64acbfa75","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":948849,"visible":true,"origin":"","legend":"","description":"","filename":"FigureFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/e01275cd373da42dc6ea94d5.docx"},{"id":98022809,"identity":"5b781d2e-b677-4f1c-bb81-c23b19f02f86","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":31505,"visible":true,"origin":"","legend":"","description":"","filename":"RevisedManuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/04a5dd455bf036b462e62404.docx"},{"id":98427326,"identity":"b7cc6545-7d41-4189-919e-49fb5025ca28","added_by":"auto","created_at":"2025-12-17 16:40:08","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8272,"visible":true,"origin":"","legend":"","description":"","filename":"dfbcf685210b42fd9a2339e850d1512f.json","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/1ec74e4141e6494d75bf18a5.json"},{"id":98022810,"identity":"22266cd9-5ce0-4d44-9a8b-c5d2effd8689","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53395,"visible":true,"origin":"","legend":"","description":"","filename":"dfbcf685210b42fd9a2339e850d1512f1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/ed8c40df48cde118ba4aeec1.xml"},{"id":98427086,"identity":"3f76e105-14ad-4f4e-a83b-b66cdcec4bdb","added_by":"auto","created_at":"2025-12-17 16:39:32","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":455872,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/5945848bead54ed9cde11790.jpeg"},{"id":98427489,"identity":"1cf55d27-1ce6-432a-b5d2-1093b9832359","added_by":"auto","created_at":"2025-12-17 16:40:33","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":613450,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/b60b34ba1b8c2efba6725357.jpeg"},{"id":98426708,"identity":"76830ba5-a08e-47f0-b5cc-2104615e7a3b","added_by":"auto","created_at":"2025-12-17 16:38:14","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":785522,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/4dff17e8ae3c235d622716b1.jpeg"},{"id":98022819,"identity":"fd39a951-9aa5-4b6d-9704-1251cf78979c","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":359747,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/b41a6843a62963c08d963604.jpeg"},{"id":98022818,"identity":"e4eba914-7559-4cdd-b352-70ba7f097a61","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"emf","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21944,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.emf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/34495a3334ec65be3c8ca0b1.emf"},{"id":98426037,"identity":"35a4c218-219b-4360-a20a-2112b9e5c889","added_by":"auto","created_at":"2025-12-17 16:35:32","extension":"emf","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24788,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.emf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/ccca660d0b3607718540d245.emf"},{"id":98424923,"identity":"9c1929e8-0b83-43a3-89b9-4e453a845581","added_by":"auto","created_at":"2025-12-17 16:34:03","extension":"emf","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36512,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.emf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/86f31a56e114f28fcf7995fe.emf"},{"id":98022824,"identity":"7104c84c-7593-459c-99a0-1b0f35244df3","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"emf","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28916,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.emf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/06a487958d0fafefe575818d.emf"},{"id":98022827,"identity":"9874357f-5abb-41ab-950a-907b226edc9e","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"emf","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32864,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage9.emf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/3c3869096b9d048debaf315a.emf"},{"id":98427088,"identity":"13196bb1-e22f-4977-8ec7-5334f142dd41","added_by":"auto","created_at":"2025-12-17 16:39:32","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125443,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/3acd55dfb345b376097cf655.png"},{"id":98022833,"identity":"d2f05fc0-2110-42f0-b3ae-ca5a4d092030","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135275,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/a6e908c941c126ac1bd99730.png"},{"id":98426558,"identity":"fc91023d-dbc4-40d1-8058-8bebceed2e5e","added_by":"auto","created_at":"2025-12-17 16:36:47","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":203846,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/6209dad9d65d916fb1ffbc73.png"},{"id":98426454,"identity":"e569ec07-b0e5-47d3-862f-bed040fd4bee","added_by":"auto","created_at":"2025-12-17 16:36:24","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":93405,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/11a3cca75ff61ebb49bbaadc.png"},{"id":98022822,"identity":"7e0aca56-354e-4571-a03c-562d2de0d5f5","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5023,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/3a7f196c9c1c5af7c6fcb49a.png"},{"id":98424858,"identity":"22dbc718-b376-45fc-b66c-19b0e9bb8a42","added_by":"auto","created_at":"2025-12-17 16:33:57","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10786,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/044e0ec5616d879c3ae5140c.png"},{"id":98425636,"identity":"9ec95feb-a928-4901-a04f-64bfc6b83684","added_by":"auto","created_at":"2025-12-17 16:35:00","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21257,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/b81232997d289ccec3676299.png"},{"id":98426717,"identity":"9458cb2d-5883-441e-9a5f-6dc5a5bb06ae","added_by":"auto","created_at":"2025-12-17 16:38:15","extension":"png","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16045,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/ac13971310631b9779a80cda.png"},{"id":98022828,"identity":"ca798d32-8dfc-4ee1-a77c-d0c13f12c708","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":33755,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/44289ffb5dda271012060b34.png"},{"id":98426579,"identity":"3fe0c679-749d-4343-8f49-de9372ccb4ab","added_by":"auto","created_at":"2025-12-17 16:36:59","extension":"xml","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":50383,"visible":true,"origin":"","legend":"","description":"","filename":"dfbcf685210b42fd9a2339e850d1512f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/705dc9bde885825bb1b6df66.xml"},{"id":98022836,"identity":"2f69d042-0a54-4dc1-acb4-97f4c89df93f","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"html","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61352,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/4e9ccb86907503b36bba27e3.html"},{"id":98425973,"identity":"1239c6d4-6198-41b5-aad1-d7c1b967733e","added_by":"auto","created_at":"2025-12-17 16:35:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":291832,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCoronal contrast-enhanced CT of the chest and abdomen demonstrating a large left-sided hemothorax with near-complete collapse of the left lung. The mediastinum is displaced rightward due to mass effect.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/37c4d3f8455ba8b17b759b44.png"},{"id":98022816,"identity":"8e055a3b-ba2b-4213-b492-ee44c0a0b49e","added_by":"auto","created_at":"2025-12-12 01:13:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":385798,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAxial contrast-enhanced CT image showing a massive left hydropneumothorax with an air–fluid level and compressive atelectasis of the underlying lung.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/5d52d49ed359d94f93cf5b60.png"},{"id":98426523,"identity":"24ee24ba-4f93-4f39-88ec-ce70c2d4ec47","added_by":"auto","created_at":"2025-12-17 16:36:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":507593,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCoronal CT demonstrating a multiloculated left pleural effusion with internal septations and partial lung collapse. No evidence of intrathoracic mass or parenchymal lesion is seen.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/ba0565b66481d89180d892fc.png"},{"id":98426891,"identity":"362ddaf4-5aea-4594-a8cf-795d8155b919","added_by":"auto","created_at":"2025-12-17 16:38:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":203414,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAxial contrast-enhanced CT at the level of the heart showing a large heterogeneous left pleural collection consistent with hemothorax. The descending thoracic aorta is visible but without a clearly identifiable intimal flap in this slice.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/744e4fb7bac11dd427a21f81.png"},{"id":98776949,"identity":"dacb29cb-2561-4d23-bc58-af8147cab033","added_by":"auto","created_at":"2025-12-22 12:24:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2300057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/1c6d97bc-776d-4d7b-96d3-26ac99614d3b.pdf"},{"id":98424824,"identity":"24c99153-cf28-49dc-bfc4-70ab0b7ecd72","added_by":"auto","created_at":"2025-12-17 16:33:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33903,"visible":true,"origin":"","legend":"","description":"","filename":"TableFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-8214584/v1/a841add8d2b9caaa49c93d3d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stanford Type B Aortic Dissection Presenting as a Massive Hemothorax: A Case Report","fulltext":[{"header":"Highlights","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eA rare presentation of Stanford Type B aortic dissection manifesting as a massive left hemothorax and hydropneumothorax.\u003c/li\u003e\n \u003cli\u003ePleural fluid analysis with very high LDH and low glucose indicated hemorrhagic exudate associated with the aortic event.\u003c/li\u003e\n \u003cli\u003eDespite initial instability, end-organ perfusion was preserved through the true lumen on CT angiography.\u003c/li\u003e\n \u003cli\u003eConservative management with strict blood pressure control achieved stabilization without the need for TEVAR.\u003c/li\u003e\n \u003cli\u003eRapid clinical improvement allowed chest tube removal and discharge by day seven.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction","content":"\u003cp\u003eAcute aortic dissection (AAD) is a catastrophic vascular emergency characterized by the separation of the aortic wall layers, creating a false lumen that may compromise end-organ perfusion or rupture. Based on the Stanford classification, dissections involving the ascending aorta are classified as Type A, requiring immediate surgical intervention, while those limited to the descending aorta are classified as Type B [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While systemic hypertension is the most significant risk factor for AAD, the clinical presentation is often variable, ranging from classic tearing chest pain to syncope or neurological deficits.\u003c/p\u003e\u003cp\u003eHemothorax is a rare but lethal complication of AAD, typically signifying a rupture of the descending thoracic aorta into the pleural space. Spontaneous hemothorax is most frequently associated with malignancy or pneumothorax; however, vascular etiologies like aortic dissection account for a small but critical subset of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although massive hemothorax in the context of Type B aortic dissection (TBAD) often necessitates urgent thoracic endovascular aortic repair (TEVAR) or open surgery, select cases may stabilize with aggressive medical management if the rupture is contained [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe present a case of a 40-year-old female with a history of hypertension who presented with a massive left-sided hemothorax secondary to a Stanford Type B aortic dissection. This case highlights the diagnostic challenge of aortic dissection presenting primarily with pleural manifestations and demonstrates the successful outcome of conservative management in a patient with preserved end-organ perfusion. The manuscript has been prepared according to the TITAN checklist [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the CARE checklist [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 40-year-old woman presented to the emergency department with the sudden onset of severe chest pain radiating to the back, accompanied by diaphoresis and a positional dry cough that prevented her from lying supine. She had a 10-year history of hypertension and long-standing joint pain previously labeled as rheumatoid arthritis, though she had received only symptomatic therapy. Recent spinal imaging provided context for her chronic pain, revealing a reversal of cervical lordosis with prominent osteophyte complexes at C4–C5 and C5–C6 causing canal stenosis, alongside degenerative disc disease at L3–L4 and L4–L5.\u003c/p\u003e\n\u003cp\u003eOn arrival, the patient appeared visibly distressed. Her vital signs demonstrated hypertensive urgency with a blood pressure of 180/90 mmHg, tachycardia (pulse 110/min), tachypnea (respiratory rate 29/min), and hypoxia (oxygen saturation 91% on room air). Complete Arterial blood Gas Analysis was done, which is given in \u003cstrong\u003eTable 1\u003c/strong\u003e. Respiratory examination revealed markedly decreased breath sounds over the left hemithorax, with stony dullness and reduced vocal fremitus, while the cardiovascular examination was otherwise unremarkable.\u003c/p\u003e\n\u003cp\u003eElectrocardiography showed sinus tachycardia with new ST-segment depressions in the anterior leads. Cardiac biomarkers were elevated, with a high-sensitivity Troponin-I of 120.84 pg/mL (reference \u0026lt;27 pg/mL), suggestive of myocardial strain secondary to the acute aortic event.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDetailed laboratory evaluation was performed to assess systemic involvement. Hematologic testing revealed severe normocytic anemia with a hemoglobin of 7.4 g/dL and an MCV of 84 fl, alongside reactive thrombocytosis (platelet count 502 × 10⁹/L) and a normal total leukocyte count of 8.5 × 10⁹/L, though mild lymphopenia (17%) was noted \u003cstrong\u003e(Table 2)\u003c/strong\u003e. Biochemical profiling on admission demonstrated mild acute kidney injury, with a urea of 36 mg/dL and creatinine of 1.40 mg/dL. Electrolyte analysis revealed significant hypokalemia (2.01 mEq/L) with normal sodium levels (135.9 mEq/L). Liver function tests were largely preserved (Total Bilirubin 0.54 mg/dL, ALT 35.9 U/L), although Alkaline Phosphatase was transiently elevated at 154 U/L. To clarify the etiology of her joint pain, autoimmune serology was performed; both Rheumatoid Factor (\u0026lt;20.0 IU/mL) and Anti-CCP (\u0026lt;0.5 U/mL) were negative, suggesting seronegative arthritis or degenerative joint disease rather than active rheumatoid arthritis \u003cstrong\u003e(Table 3).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChest radiography demonstrated complete opacification of the left hemithorax consistent with a large hemothorax \u003cstrong\u003e(Figures 1, 2, and 4)\u003c/strong\u003e. CT angiography confirmed a Stanford Type B aortic dissection. The dissection originated just distal to the left subclavian artery and extended to the inferior mesenteric artery. The true and false lumens were clearly delineated, with the celiac trunk, superior mesenteric artery, and both renal arteries arising from the true lumen. A loculated left hydropneumothorax with internal septations and air–fluid levels was also visualized \u003cstrong\u003e(Figure 3).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA left intercostal chest tube was inserted, draining hemorrhagic pleural fluid. Analysis of the fluid revealed a grossly hemorrhagic exudate (RBC 3007/µL, hemolysis index 12818) with a protein level \u0026gt;17.2 g/dL and markedly elevated LDH (\u0026gt;4395 U/L). Glucose was critically low (\u0026lt;25 mg/dL). Microbiology and cytology returned negative for organisms and malignant cells, ruling out empyema and malignancy \u003cstrong\u003e(Table 4).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing multidisciplinary evaluation, conservative management was selected as there was no evidence of frank rupture or end-organ malperfusion. Blood pressure control was achieved with oral bisoprolol and valsartan. With hemodynamic stabilization and rehydration, her renal function normalized (creatinine improved to 0.69 mg/dL and urea to 22 mg/dL) and alkaline phosphatase levels returned to normal range (67 U/L). The chest tube was removed after drainage subsided and lung re-expansion was confirmed.\u003c/p\u003e\n\u003cp\u003eBy day 7, the patient was hemodynamically stable, chest-tube free, and maintaining oxygen saturation on room air. She was discharged on antihypertensives with strict blood pressure monitoring and scheduled outpatient CT follow-up.\u003c/p\u003e\n\u003cp\u003eA table showing the complete chronological sequence of events is given in \u003cstrong\u003eTable 5.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eStanford Type B aortic dissection (TBAD) accounts for approximately one-third of all aortic dissections. The classic presentation involves sudden, severe back or chest pain; however, the clinical picture can be obscured by complications such as pleural effusion or hemothorax [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this patient, the presence of a massive hemothorax initially raised concerns for a primary pleuropulmonary pathology or malignancy, but the acute onset of pain and hypertensive urgency pointed toward a vascular etiology.\u003c/p\u003e\u003cp\u003eThe mechanism of hemothorax in AAD typically involves the transudation of fluid across the thin wall of the false lumen or a frank rupture into the pleural cavity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While left-sided hemothorax is more common due to the anatomical proximity of the descending aorta to the left pleural space, right-sided presentations have also been documented [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our case, the fluid analysis revealed a hemorrhagic exudate with high lactate dehydrogenase (LDH) and low glucose, consistent with the localized metabolic derangement caused by the breakdown of blood in the pleural space.\u003c/p\u003e\u003cp\u003eThe management of TBAD is dictated by the presence of complications. Uncomplicated TBAD is generally managed medically with strict blood pressure control (anti-impulse therapy). Conversely, complicated TBAD\u0026mdash;defined by rupture, malperfusion, or refractory pain\u0026mdash;often requires intervention, such as TEVAR [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A ruptured AAD presenting with hemothorax is traditionally an indication for urgent repair to prevent exsanguination [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, in this unique case, CT angiography demonstrated that the visceral arteries (celiac, SMA, and renal) originated from the true lumen, ensuring end-organ perfusion. Furthermore, the patient stabilized hemodynamically after initial tube thoracostomy and aggressive antihypertensive therapy.\u003c/p\u003e\u003cp\u003eRecent literature suggests that extrapleural hematomas or contained ruptures in TBAD can sometimes be managed conservatively if the patient remains stable [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This aligns with our approach, where the absence of active contrast extravasation on repeat imaging and the cessation of pleural output allowed for a non-surgical resolution. This case emphasizes that while hemothorax in TBAD is a surgical emergency red flag, careful selection of patients for conservative management is possible when hemodynamic stability is achieved and end-organ perfusion is preserved.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eStanford Type B aortic dissection presenting as a massive hemothorax is a high-risk clinical entity that requires a high index of suspicion, particularly in hypertensive patients with atypical chest symptoms. While hemothorax often signals frank rupture necessitating urgent TEVAR or surgical intervention, this case highlights that immediate invasive repair is not invariably required. Conservative management, characterized by strict anti-impulse therapy and close hemodynamic monitoring, can be a safe and effective strategy in select patients where end-organ perfusion is preserved via the true lumen. Clinicians should prioritize rapid CT angiography to delineate the dissection anatomy, allowing for a tailored therapeutic approach that balances the risks of intervention against the potential for medical stabilization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of AI Use:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArtificial intelligence (AI) tools, including ChatGPT, were used in drafting and editing portions of this manuscript. The final content was reviewed and approved by the authors to ensure accuracy and integrity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient. The patient gave written and informed consent, which can be provided on demand.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, this is not a clinical trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of clinical details/images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this case report are included within this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMuhammad Moin Ud Din Arshad\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization; Data curation; Investigation; Writing \u0026ndash; original draft; Visualization; Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRimsha Maqsood\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInvestigation; Data curation; Clinical management of the patient; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMesum Abbas\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFormal analysis; Resources; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAli Sher\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData curation; Acquisition of clinical and imaging data; Validation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbdul Hannan Asghar\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMethodology; Literature review; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMuhammad Bilal Akram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupervision; Clinical oversight; Critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMuhammad Abdullah Masood\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData interpretation; Radiology input; Verification of imaging findings; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmit Kumar Thakur\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall supervision; Final manuscript approval; Corresponding author responsibilities; Critical review and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOzkan F, Akpinar E, Serter T, Ozy\u0026uuml;ksel A, Hazirolan T. Ruptured type B aortic dissection presenting with right hemothorax. Diagn Interv Radiol. 2008 Mar;14(1):6-8. PMID: 18306137.\u003c/li\u003e\n\u003cli\u003ePatrini D, Panagiotopoulos N, Pararajasingham J, Gvinianidze L, Iqbal Y, Lawrence DR. Etiology and management of spontaneous haemothorax. J Thorac Dis. 2015 Mar;7(3):520-6. doi: 10.3978/j.issn.2072-1439.2014.12.50. PMID: 25922734; PMCID: PMC4387396.\u003c/li\u003e\n\u003cli\u003eAbdallah, F. , Gharsalli, H. , Kwas, H. , Taktak, S. , Chtourou, A. and Kheder, A. (2013) Hemothorax Revealing Aortic Aneurism and Aortic Dissection. \u003cem\u003eOpen Journal of Respiratory Diseases\u003c/em\u003e, 3, 113-115. doi: 10.4236/ojrd.2013.33017.\u003c/li\u003e\n\u003cli\u003eSlind RO, Rodarte JR. Selected reports. Spontaneous hemothorax in an otherwise healthy young man. Chest. 1974 Jul;66(1):81. doi: 10.1378/chest.66.1.81. PMID: 4843606.\u003c/li\u003e\n\u003cli\u003eSong P, Bachman A, Kelly L. Late Diagnosis of a Large Extrapleural Hematoma in a Patient With Stanford Type B Aortic Dissection: A Case Report and Review of Literature. J Cardiothorac Vasc Anesth. 2022 Apr;36(4):1118-1122. doi: 10.1053/j.jvca.2021.01.010. Epub 2021 Jan 12. PMID: 33549486.\u003c/li\u003e\n\u003cli\u003eChang, Jui-Tsung \u0026amp; Lin, Yi-Chang. (2019). Acute Type B aortic dissection with right hemothorax. Journal of Medical Sciences. 39. 10.4103/jmedsci.jmedsci_136_18. \u003c/li\u003e\n\u003cli\u003eTakago S, Nishida S, Noda Y, Nosaka Y, Yamamoto T. Thoracic endovascular aortic repair of a ruptured acute type B aortic dissection presenting with right hemothorax: a case report and review of the literature. Gen Thorac Cardiovasc Surg. 2021 Oct;69(10):1438-1443. doi: 10.1007/s11748-021-01678-2. Epub 2021 Jun 30. PMID: 34195926.\u003c/li\u003e\n\u003cli\u003eLiu, B., Ma, D., Bai, Y. \u003cem\u003eet al.\u003c/em\u003e Large extrapleural hematoma in a patient with Stanford type B acute aortic dissection: a case report. \u003cem\u003eJ Med Case Reports\u003c/em\u003e 19, 348 (2025). https://doi.org/10.1186/s13256-025-05400-1\u003c/li\u003e\n\u003cli\u003eTrimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, Tolva V, Deeb MG, Upchurch GR Jr, Cooper JV, Fang J, Isselbacher EM, Sundt TM 3rd, Eagle KA; IRAD Investigators. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006 Jul 4;114(1 Suppl):I357-64. doi: 10.1161/CIRCULATIONAHA.105.000620. PMID: 16820600.\u003c/li\u003e\n\u003cli\u003eNienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015 Feb 28;385(9970):800-11. doi: 10.1016/S0140-6736(14)61005-9. Epub 2015 Feb 6. PMID: 25662791.\u003c/li\u003e\n\u003cli\u003eKerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA. Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier Journal of Science 2025:10;100079.\u003c/li\u003e\n\u003cli\u003eRiley DS, Barber MS, Kienle GS, AronsonJK, et al. CARE guidelines for case reports: explanation and elaboration document. \u003cem\u003eJClinEpi\u003c/em\u003e 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stanford Type B Aortic Dissection, Hemothorax, Anti-impulse therapy, Conservative management, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-8214584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8214584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStanford Type B aortic dissection (TBAD) is a critical vascular emergency typically presenting with acute tearing chest or back pain. While pleural effusions are common in TBAD, presentation as a massive hemothorax is a rare and life-threatening complication that often signals aortic rupture, traditionally necessitating urgent surgical or endovascular intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase Presentation:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe report the case of a 40-year-old female with a ten-year history of hypertension who presented with severe chest pain, diaphoresis, and dyspnea. Physical examination revealed signs of massive left-sided pleural effusion, and laboratory evaluation demonstrated severe anemia and acute kidney injury. Computed Tomography (CT) angiography confirmed a Stanford Type B aortic dissection extending from the left subclavian artery to the inferior mesenteric artery, complicated by a massive left hydropneumothorax. Crucially, the celiac trunk, superior mesenteric artery, and renal arteries originated from the true lumen, preserving end-organ perfusion.\u003c/p\u003e\u003cp\u003e\u003cb\u003eManagement and Outcome:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite the presence of hemothorax, the patient was hemodynamically responsive to resuscitation. A left intercostal chest tube was placed, draining hemorrhagic fluid. She was managed conservatively with aggressive anti-impulse therapy (strict blood pressure control). The patient stabilized rapidly without the need for Thoracic Endovascular Aortic Repair (TEVAR), renal function normalized, and she was discharged on the seventh day.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis case illustrates that while hemothorax in the setting of Type B aortic dissection is a red flag for rupture, it does not universally mandate surgical repair. In hemodynamically stable patients with preserved visceral perfusion, a conservative approach comprising tube thoracostomy and strict blood pressure control can yield successful outcomes.\u003c/p\u003e","manuscriptTitle":"Stanford Type B Aortic Dissection Presenting as a Massive Hemothorax: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 01:13:47","doi":"10.21203/rs.3.rs-8214584/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86bebeb4-edfa-4abb-bf8b-0fbaa9e3fe5a","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T06:09:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 01:13:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8214584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8214584","identity":"rs-8214584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}