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We report a fatal case of a 61-year-old male with a history of untreated arterial hypertension who presented with acute chest pain initially mimicking anterior ST-elevation myocardial infarction (STEMI). Computed tomography (CT) revealed an acute type B aortic syndrome with intramural hematoma and a focal entry-like intimal disruption behind the left subclavian artery, associated with suspected extravasation, hemomediastinum, and bilateral spontaneous massive hemothorax. Autopsy confirmed IMHB with rupture and pseudoaneurysm formation, the immediate cause of death was hemorrhagic shock due to aortic rupture. Histologic examination, including special stains (elastic van Gieson and Alcian blue), revealed no elastic fiber fragmentation, no mucoid extracellular matrix accumulation, and no cystic medial degeneration. This case illustrates a rare and fulminant presentation of bilateral spontaneous hemothorax complicating IMHB without identifiable histologic aortopathy. Although overall in-hospital mortality in uncomplicated IMHB is low, complications such as aortic rupture with bilateral hemothorax carry dramatically higher mortality.<\/jats:p>","DOI":"10.1007\/s12024-026-01302-w","type":"journal-article","created":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T04:56:21Z","timestamp":1782104181000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A rare bilateral spontaneous severe hemothorax in intramural hematoma type B with unremarkable aortic histology: a case report and literature review"],"prefix":"10.1007","author":[{"given":"Silvia Farka\u0161ov\u00e1","family":"Iannaccone","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6946-3765","authenticated-orcid":false,"given":"Tibor","family":"Poruban","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roman","family":"Koribsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mikulas","family":"Hunavy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Vasovcak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hana","family":"Hrazderova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alzbeta","family":"Ginelliova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Farkas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"issue":"9","key":"1302_CR1","doi-asserted-by":"publisher","first-page":"2331","DOI":"10.1111\/jocs.14819","volume":"35","author":"JA Brown","year":"2020","unstructured":"Brown JA, Arnaoutakis GJ, Kilic A, Gleason TG, Aranda-Michel E, Sultan I. 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Ann Vasc Surg. 2024;101:195\u2013203.","journal-title":"Ann Vasc Surg"}],"container-title":["Forensic Science, Medicine and Pathology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12024-026-01302-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s12024-026-01302-w","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12024-026-01302-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T04:56:23Z","timestamp":1782104183000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s12024-026-01302-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,22]]},"references-count":15,"alternative-id":["1302"],"URL":"https:\/\/doi.org\/10.1007\/s12024-026-01302-w","relation":{},"ISSN":["1556-2891"],"issn-type":[{"value":"1556-2891","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,22]]},"assertion":[{"value":"13 February 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 June 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 June 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (IRB\/ERC of the East Slovak Institute of Cardiovascular Diseases, Kosice, Slovakia, Reference number 27329571\n                      \/Etick\u00e1 komisia pri spolo\u010dnosti V\u00fdchodoslovensk\u00fd \u00fastav srdcov\u00fdch a cievnych chor\u00f4b\n                      ,\n                      a.s.\/\n                      ) and with the Helsinki Declaration of 1975, as revised in 2008, and approved by this committee.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Clinical trial number"}},{"value":".Farkasova Iannaccone, T. Poruban, R. Koribsky, M. Hunavy, P. Vasovcak, H. Hrazderova, A. Ginelliova, and D. Farkas declare that they have no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}