[Emphysema evaluation of the remaining lung post lobectomy].

The aim of this study was to confirm that the emphysematous changes had increased in the remaining lung on the operation side after lobectomy. Fourteen patients underwent quantitative analysis by computed tomography (CT) and respiratory function testing before and after the operation for upper or lower lobectomy of the lung between March 2005 and May 2007. The degree of emphysema was calculated by dividing the volume of the emphysematous region (CT values: -1,024 to -950 HU) by the volume of the entire lung (CT values: -1,024 to -600 HU) using a 1 mm thickness high resolution CT slice. Comparison by paired t-test showed significant differences between the emphysema rates pre and post operation in the operation side lung (15.3 +/- 7.9% and 21.7 +/- 10.0%, p = 0.02), but there were no significant differences in the contralateral lung (15.8 +/- 7.5% and 17.7 +/- 8.4%, p = 0.25). On the other hand, there was no significant change in the percent forced expiratory volume in one second (FEV1.0%) between pre and post operation (74.4 +/- 10.5% and 75.5 +/- 7.5%, p = 0.60). We consider that it is necessary to note that the emphysematous changes increased in the remaining lung on the operation side after lobectomy even though the FEV1.0% did not decrease at present.

Human herpesvirus 8 (HHV8) sequence variations in HHV8 related tumours in Okinawa, a subtropical island in southern Japan.

BACKGROUND: Although rare in mainland Japan, classic Kaposi's sarcoma (KS) is frequently reported in Okinawa, a subtropical island in southern Japan. Human herpesvirus 8 (HHV8) has been identified in the tumours and geographical differences occur. AIM: To sequence HHV8 in classic and AIDS associated KS in Okinawa. MATERIALS/METHODS: Eight classic KS cases, one AIDS associated KS, five granuloma pyogenicum cases, two inflammatory pseudotumours, two Castleman's disease cases, one angiosarcoma, and one primary effusion lymphoma (PEL) were studied. As a control, HHV8 positive cultured PEL cells (TY-1) were used. The presence of HHV8 sequences was evaluated by PCR and in situ hybridisation. PCR products were sequenced. RESULTS: There were no histological differences among KS resulting from the different virus genotypes. HHV8 was detected in all cases of KS, in one PEL, and one granuloma pyogenicum. Eight classic KS cases and one granuloma pyogenicum were infected with HHV8 genotype II/C (K1 region) or subtype C (ORF26 region), which had a five amino acid deletion at K1 VR2 region. An AIDS associated KS and a PEL were infected with type I/A virus. CONCLUSION: In Okinawa, classic KS cases and one granuloma pyogenicum case were infected with HHV8 genotype II/C, also classified as subtype C. AIDS associated KS and PEL were infected with a different HHV8 (genotype I/A), similar to that found in the USA. In Okinawa, HHV8 infection is more than four times higher than in mainland Japan, resulting in many cases of KS because of HHV8 genotype II/C infection.

Differences in EBNA2 and LMP-1 carboxy terminal region sequences of Epstein-Barr virus type A between the tumors in a multiple cancer patient.

Using PCR, type A Epstein-Barr virus (EBV) infection was demonstrated in a squamous cell carcinoma of the maxilla (in a 52-year-old man) and the tongue of the same patient 18 years later (at the age of 70). Furthermore, at the age of 72, this patient developed an EBV-infected anaplastic large cell lymphoma. Analysis of the terminal regions of the EBV genome revealed a monoclonal proliferation of EBV-infected lymphoma cells. However, sequence analysis of the EBV revealed a slight difference in the EBNA2 regions between the virus-infected lymphoma and the squamous cell carcinomas. The mutations at 48991 (G-->T) and 48998 (C-->A) were demonstrated in the lymphoma. Although the squamous cell carcinoma of the tongue occurred after an interval of 18 years, the mutation site in the carcinomas was the same, 49137 (A-->G), as compared with B95-8 strain EBV EBNA2. The mutations at 48991 and at 49137 were associated with amino acid changes, Arg-->Met and Thr-->Ala, respectively, but the alteration at 48998 was a silent mutation. Thirty-bp deletion in the LMP-1 carboxy terminal region was demonstrated in the virus-infected lymphoma, but not in the squamous cell carcinomas. On the other hand, HTLV-1 proviral DNA (tax, gag and env) was not detected in the lymphoma, nor was HPV demonstrated in the squamous cell carcinomas, although Okinawa is known as an HTLV-1 and HPV prevalence region. The T-cell receptor beta gene rearrangement was demonstrated in the lymphoma, but the t(2;5) fusion transcript was not detected using PCR. Cytogenetic analysis of the lymphoma cells showed a complex hypertriploid karyotype with 76XY. The type A EBV infection might play a role in the carcinogenesis of the tumors of our patient. Interestingly, the infected virus genome sequences, the EBNA2 and LMP-1 regions, which were closely associated with carcinogenesis in the squamous cell carcinomas and the lymphoma, showed slight differences.

Extremely high Langerhans cell infiltration contributes to the favourable prognosis of HPV-infected squamous cell carcinoma and adenocarcinoma of the lung.

AIMS: The infiltration of Langerhans cells in adenocarcinomas and squamous cell carcinomas of the lung was examined in relation to prognostic implications and human papillomavirus (HPV) infection. METHODS AND RESULTS: Samples from 62 adenocarcinoma and 59 squamous cell carcinoma patients in 1995-97, the prognosis of which had been followed up, were used. The Langerhans cells were demonstrated immunohistochemically using anti S100a and CD1 antibodies. Human papillomavirus (HPV) infection was examined by polymerase chain reaction (PCR) and nonisotopic in-situ hybridization (NISH) methods. Statistical analysis was carried out using the Kaplan-Meier method (Wilcoxon analysis) and multiple regression analysis. HPV infection was demonstrated in 12 cases (19.4%) of adenocarcinoma. The HPV-infected adenocarcinomas had abundant faintly eosinophilic cytoplasm, and were immunohistochemically positive for the surfactant apoprotein A. In the 59 cases of squamous cell carcinomas 19 were of the well differentiated form, and 29 and 11 were moderately and poorly differentiated cases, respectively. HPV was detected in 29 cases (49.2%) (13 well and 16 moderately differentiated cases). In all HPV-infected adenocarcinoma and squamous cell carcinoma cases, extremely large numbers of Langerhans cells (more than 100 per high-power field) were demonstrated in the tumour nests. In contrast, in the non-HPV-infected adenocarcinomas and squamous cell carcinomas, only a few (less than about 10 per high-power field) Langerhans cells were observed. The squamous cell carcinoma cases with high Langerhans cell infiltration, which were also infected with HPV, showed a significantly good prognosis (P = 0.007). The adenocarcinoma cases with high Langerhans cell infiltration tended to have a better prognosis than the cases with low Langerhans cell infiltration, but the difference was not statistically significant. The low number of highly infiltrated cases was insufficient for an adequate statistical analysis. Furthermore, there was no significant correlation between either Langerhans cell infiltration and smoking, or HPV infection and smoking, in either squamous cell carcinoma or adenocarcinoma cases. CONCLUSIONS: It was considered that the extremely high Langerhans cell infiltration in the tumours was caused by HPV infection. The extremely large number of Langerhans cells in the tumours contributes to the favourable prognosis for HPV-infected lung cancer.

Recent striking changes in histological differentiation and rate of human papillomavirus infection in squamous cell carcinoma of the lung in Okinawa, a subtropical island in southern Japan.

AIMS: The incidence of lung cancer in Okinawa has been the highest in Japan since 1975, and squamous cell carcinoma (SCC), especially the well differentiated form, is the most prevalent form in Okinawa, although well differentiated SCC is relatively rare in mainland Japan. Furthermore, a high proportion of SCC of the lung in Okinawa was positive for human papillomavirus (HPV). In this study, we report recent striking changes in histological features and in the incidence of HPV infection. METHODS: In Okinawa between 1986 and 1998, 1109 surgically resected lung tumours were examined histopathologically. In addition, human papillomavirus infection was detected by the polymerase chain reaction and Southern blot analysis in SCC cases reported in 1993 and 1995-8. Non-isotopic in situ hybridisation of HPV DNA was also carried out. RESULTS: Up until 1994 SCC, especially the well differentiated form, was the most prevalent type of tumour. However, since 1995 the number of such cases has diminished steadily, accompanied by a slight rise in the incidence of adenocarcinoma. Although most present and past patients are heavy smokers, the incidence of SCC, especially the well differentiated form, continues to decrease steadily. Furthermore, in 1993, HPV was detected in 79% of all cases, and was particularly prevalent in the well differentiated form, but the rate fell to 68% in 1995, 35% in 1996, 23% in 1997, and 24% in 1998. The age distribution of patients, the male to female ratio, and the number of tumours overexpressing p53 protein did not change significantly over the study period, and thus did not correlate with changes in the differentiation of SCC. CONCLUSIONS: The decreasing incidence of viral infection correlates strongly with the falling numbers of SCC cases, especially well differentiated cases. These findings suggest that HPV might be involved in the development of SCC of the lung, affecting the histological differentiation of SCC in particular, at least in Okinawa, a subtropical island in southern Japan.

Experimental myelitis in BALB/cN and C57BL/6N mice caused by herpes simplex virus type 1 compared with herpes simplex virus type 2.

Intraperitoneal and footpad inoculations of herpes simplex virus type 1 (HSV) into BALB/cN (HSV-susceptible) and C57BL/6N (HSV-resistant) mice were carried out to induce experimental myelitis. Standard laboratory strains (McIntyre, F, RK, and recently Okinawa strain R1) were inoculated in mice. As a control, the HSV 2 standard laboratory strain SAV was also inoculated. The McIntyre strain was the most virulent, while the F strain was the least. RK and R1 were both moderately virulent. Myelitis was induced in BALB/cN mice after intraperitoneal and footpad inoculations of low to high doses of the McIntyre strain, and intraperitoneal inoculation of moderate and high doses of the RK and R1 strains. Symptoms of paraplegia of the hind legs and rectal and urinary incontinence were observed, but not until 3-5 hours before death. The symptoms caused by footpad inoculation were slightly different from those following intraperitoneal inoculation; rectal incontinence, in particular, was inconspicuous in the former. In the case of footpad inoculation of RK and R1, only one mouse inoculated with R1 showed symptoms and histology of myelitis. The F strain caused no symptoms. In the case of C57BL/6N mice, high dose intraperitoneal and footpad inoculations of the McIntyre strain also caused myelitis, and the symptoms were observed about 6-7 hours before death. In only one C57BL/6N mouse intraperitoneally inoculated with a high dose of R1 did symptoms appear about 6 hours before death. The same symptoms caused by intraperitoneal and footpad inoculations of HSV 2 (SAV) were observed more clearly and for a longer period (half to one day) than those caused by HSV 1 inoculation. Spinal cord necrosis was noted with McIntyre, RK and R1 inoculations, but it was not marked with randomly located foci, when compared with that caused by SAV. Further, the foci of necrosis in C57BL/6N mice were smaller than in BALB/cN mice, even when high dose McIntyre strain was used. Nuclear pyknosis and edema of the brain in the dead mice following HSV 1 inoculation were more marked than in those killed by SAV.

Rhabdoid tumour of the lung is a dedifferentiated phenotype of pulmonary adenocarcinoma.

AIMS: Primary rhabdoid tumour of the lung is rare, and histological and biological characteristics have not been fully documented. We describe three cases of primary lung rhabdoid tumour, all associated with adenocarcinoma, and investigate the histological features and biological characteristics. METHODS AND RESULTS: Three cases were obtained from a total 902 cases of surgically removed primary lung tumours between 1986 and 1998. The rhabdoid cells were found to occupy about 50-90% of each tumour. All of the tumours had nonrhabdoid adenocarcinoma foci in the centre of the tumours. Transition between the adenocarcinomatous and rhabdoid components was demonstrated. Detailed immunohistochemical studies were carried out. The epithelial markers, cytokeratins and epithelial membrane antigen (EMA), were strongly expressed in rhabdoid and adenocarcinomatous components. Furthermore, surfactant apoprotein A was positive in both components in one case, but myoglobin, MyoD and HHF35 were not expressed. Vimentin was strongly and diffusely stained in all cases. The neuroendocrine markers, chromogranin A (all cases), neuron-specific antigen (NSE) (two cases) and CD56 (one case) were occasionally positive in only a small number of the rhabdoid tumour cells. GM-CSF was positively stained in one case, and the dedifferentiated characteristics of the rhabdoid cells was suggested. Proliferative cell nuclear antigen (PCNA) was strongly demonstrated in the rhabdoid tumour cells (all cases). To gain better understanding the highly proliferative characteristics of the tumours, p53 gene (exons 5-8) mutation was examined by DNA sequencing analysis; mutation of the p53 DNA was not detected. Overexpression of p53 protein was also not demonstrated in all cases. HPV6 was demonstrated in one case by PCR method and also non-isotopic in-situ hybridization (NISH). Two cases died in a short period of time (3 years and 4 months, respectively). CONCLUSION: The rhabdoid cells in these three cases were considered to represent the dedifferentiated components of the accompanying adenocarcinoma. Dedifferentiated characteristics (neuroendocrine markers, GM-CSF, vimentin, and the aggressive behaviour) were evident.

Prognostic implication of human papillomavirus infection in squamous cell carcinoma of the lung.

On the subtropical island of Okinawa, squamous cell carcinoma (SCC), particularly the well-differentiated form, is the most frequent type of lung cancer, while this form is relatively rare on the Japanese mainland and in other countries. Furthermore, in Okinawa, in 1993, 80% of SCC cases of the lung were found to be infected with human papillomavirus (HPV). We studied the prognosis of SCC of the lung with HPV infection (n = 25) and compared it with non-HPV-infected SCC (n = 16). Using the Kaplan-Meier method (Wilcoxon analysis), the prognosis of HPV-infected cases was found to be better than that of the non-infected cases. In the virus-infected cases, apoptosis and infiltration of a large number of Langerhans cells were demonstrated. In addition to these findings, the virus-infected tumors were demonstrated to be histologically well-differentiated, perhaps contributing to the favorable prognosis. However, among the virus-infected cases, the type 16 virus-infected cases showed a poorer prognosis, compared to those infected with other HPV types. p53 gene mutation was also examined, and was considered to be an unfavorable prognostic factor, as reported elsewhere. However, in Okinawa, HPV-positive cases with p53 mutations showed a slightly better prognosis than did non-viral infected cases with p53 mutations. The TNM staging system was also useful for categorizing the virus-infected cases. The prognosis of stage III (A and B) cases was poor. All of our present cases received surgical treatment. Chemotherapy and radiation therapy were not performed. Such treatment, however, might be effective, because virus-infected uterine cervical carcinomas have been routinely treated with chemotherapy and radiation. Furthermore, if the immunological basis of increased Langerhans cell infiltration in HPV-infected cases is elucidated, a clinical trial with immunotherapy may be favorable for the clinical outcome.

Comparative study of oral squamous cell carcinoma in Okinawa, Southern Japan and Sapporo in Hokkaido, Northern Japan; with special reference to human papillomavirus and Epstein-Barr virus infection.

In Okinawa, a subtropical island in Southern Japan, the incidence of oral squamous cell carcinoma is 1.5 times higher than that in mainland Japan. Sixty cases of oral squamous cell carcinoma from 1993 to 1996 in Okinawa and 42 cases over the same period in Sapporo were examined histologically. Human papillomavirus (HPV) and Epstein-Barr virus (EBV) were detected by polymerase chain reaction (PCR) amplification with primers specific for HPV and EBV. In situ hybridisations of the viruses were also carried out. In the case of Epstein-Barr virus, in situ PCR was also performed. Thirty-five (58.3%) Okinawan tumours were well-differentiated in type, but in Sapporo, 18 (42%) were of such type. In Okinawa, tumours of the mouth floor (10 cases, 16.7%) and oropharynx (12 cases, 20%) were frequently observed, whereas in Sapporo only five cases (12%) of each were found. HPV was demonstrated in 78% of Okinawan cases and 26.2% of Sapporon cases by PCR or non-isotopic in situ hybridisation (NISH). There were 76.6% (46 cases) of Okinawan and 38.1% (16 cases) of Sapporo cases positive for EBV by PCR. In only 12 Okinawan cases and 4 Sapporon cases, were positive signals demonstrated by in situ PCR on the cancer cells themselves. EBV was demonstrated in the large number of infiltrating lymphocytes, most of which were CD3+, and a few were CD19+. In Okinawa, HPV might be an important causative factor of oral squamous cell carcinoma and EBV a less important factor, whereas in Sapporo HPV and EBV might play only a small part in the aetiology of the tumour.

Coxsackievirus B4 myocarditis in an orangutan.

A 37-year-old female orangutan died at the zoological garden. Autopsy examination demonstrated severe coxsackievirus B4 myocarditis immunohistochemically as a cause of the death. Apoptosis of the cardiac muscle cells was observed using the TdT-mediated dUTP-biotin nick endo labeling method and was considered to play a role in the myocarditis. Congestion of the liver and both lungs due to cardiac failure was also observed. Coxsackievirus infection is found frequently in the Okinawan human population. The present orangutan's infection might have come from visitors who were allowed to go near the orangutan. Malignant tumors, severe suppurative infections, and intestinal parasite infections were not observed. Epstein-Barr virus DNA was detected in lymph nodes, but there was no Burkitt's lymphoma.

Helicobacter pylori populations in Peruvian patients.

Helicobacter pylori is an extremely diverse species. The characterization of strains isolated from individual patients should give insights into colonization and disease mechanisms and bacterial evolution. We studied H. pylori isolates from patients in the Japanese-Peruvian Polyclinic in Lima, Peru, by determining metronidazole susceptibility or resistance and by random amplified polymorphic DNA (RAPD) fingerprinting (a measure of overall genotype). Strains isolated from several biopsy specimens from each of 24 patients were studied. Both metronidazole-susceptible and -resistant strains were isolated from 13 patients, whereas strains of more than one RAPD type were isolated from only seven patients. We propose that the homogeneity in RAPD fingerprints for strains isolated from most persons reflects selection for particular H. pylori genotypes during chronic infection in individual hosts and the human diversity in traits that are important to this pathogen. Carriage of related metronidazole-resistant and -susceptible strains could reflect frequent metronidazole use in Peru and alternating selection for resistant and susceptible phenotypes during and after metronidazole therapy.

Intraoperative intrapleural hypotonic cisplatin treatment for carcinomatous pleuritis.

BACKGROUND AND OBJECTIVES: We recently developed a new intraoperative intrapleural hypotonic cisplatin treatment for carcinomatous pleuritis found at thoracotomy in non-small cell lung cancer patients. In the present study, the efficacy and adverse events of this treatment as well as the pharmacokinetics of cisplatin in the blood after the treatment were evaluated. PATIENTS AND METHODS: Twenty-one patients received the treatment for 15 minutes after completing the intrathoracic surgical procedures. The total and free platinum levels in the blood of five patients were then measured. As a control, 29 patients without such treatment were reviewed retrospectively. RESULTS: The survival rates in the treatment and non-treatment groups were similar. The pleural disease free survival of the treated patients was, however, significantly higher than that of the non-treated patients. Such pleural disease as effusion and the growth of the pleural disseminated tumors only appeared in three of the 21 (14%) treated patients while 26 of 29 (90%) non-treated patients had clinically detected pleural disease. The blood platinum levels after the treatment were extremely low and such low levels probably induced no systemic adverse events after the treatment. The only adverse event of this treatment was an increase in the postoperative drainage volume. CONCLUSIONS: These observations seem to suggest that intraoperative intrapleural hypotonic cisplatin treatment for carcinomatous pleuritis found at thoracotomy can, at least, delay the appearance of the pleural disease without any adverse events.

Failure in resection of multiple pulmonary metastases from colorectal cancer.

BACKGROUND: To clarify whether or not multiple pulmonary metastases from colorectal cancer are contraindicated for a surgical resection, we retrospectively evaluated the influence of the number of pulmonary metastases on both the postthoracotomy survival and the pattern of the first failure. METHODS: From 1981 to 1993, 36 patients underwent a complete resection for pulmonary metastases from colorectal cancer. RESULTS: Of the various factors investigated including gender, primary site, disease-free interval, tumor size, the number of metastases, type of resection, and the history of hepatic metastases, only the number of pulmonary metastases was found to be significantly related to postthoracotomy survival. The rate of disease-free survival at 5 years was 62% for solitary metastasis (n = 17), 35% for two metastases (n = 8), and 0% for four or more metastases (n = 11). The pattern of failure also differed according to the number of pulmonary metastases. In particular, the incidence of local recurrence at the primary site increased with the number of pulmonary metastases (ie, 1 of 17 patients with a solitary metastasis, 3 of 8 with two metastases, and 6 of 11 with four or more metastases). CONCLUSIONS: These results suggest that multiple metastases might indicate the presence of local recurrence at the primary site; therefore, in cases of multiple pulmonary metastases, the primary site should be thoroughly explored.

Tolosa-Hunt syndrome with atypical intrasellar and juxtasellar lesions--two case reports.

Two patients with Tolosa-Hunt syndrome (THS) who had atypical lesions in the intrasellar and juxtasellar regions are reported. They manifested with painful ophthalmoplegia. Magnetic resonance imaging (MRI) commonly showed an increase in the volume of the cavernous sinus occupied by homogeneously well-enhanced lesions in both cases. These lesions extended to the intrasellar and juxtasellar regions with meningela enhancement. Follow-up MRI after steroid treatment demonstrated normalized or decreased size of the cavernous sinus. These findings suggested nonspecific inflammatory granulomatosis with atypical extension.

Transient global amnesia and dural arteriovenous fistula of the anterior cranial fossa.

Dural arteriovenous fistula (AVF) of the anterior cranial fossa is associated usually with cerebral hemorrhage or subarachnoid hemorrhage, while an association with transient global amnesia has not been reported previously. A case presenting the latter unusual symptom is described and the surgical treatment of AVF is discussed. A 64-year-old woman was hospitalized complaining of transient memory impairment. Magnetic resonance (MR) imaging demonstrated a flow void in the left frontal lobe and temporal pole. Cerebral angiography revealed an AVF in the anterior cranial fossa, which was fed bilaterally by the ethmoidal arteries and by branches of the external carotid arteries. The AVF drained into the superior sagittal sinus and the superficial sylvian vein via large varices. Following transfemoral embolization, surgical treatment was carried out. Postoperative angiography revealed complete obliteration of the anomaly. There were no further episodes of amnesia. In our presented case, there is an association between the presenting symptoms and the AVF. The combination of ischemia and congestion in the frontal and temporal lobes may have caused transient memory impairment. From our surgical experience, the excision of the vascular connection between the dura and the frontal lobe following the coagulation of the dura mater of the anterior part of the base of the skull without extensive excision seems to be recommended.

Giant aneurysm at the origin of the accessory middle cerebral artery.

BACKGROUND: Aneurysms of the A1 portion of the anterior cerebral artery are rare. The accessory middle cerebral artery is also a rare anomalous artery. CASE REPORT: We operated on a 53-year-old man because of a giant aneurysm which arose at the junction of the accessory middle cerebral artery and the horizontal portion of the anterior cerebral artery (A1 portion). CONCLUSION: This is the first report of a giant aneurysm of that region. A detailed evaluation of the angiogram is necessary prior to the operation, in order to select the most appropriate operative method to secure the blood flow of the accessory middle cerebral artery and distal anterior cerebral artery.

Postoperative chronic subdural hematoma following craniotomy--four case reports.

Postoperative chronic subdural hematoma (CSH) following craniotomy developed in only four of 372 patients undergoing craniotomy for aneurysm surgery (1 patient) and brain tumor surgery (3 patients) between April, 1991 and November, 1993, an incidence of only 1.1%. There were three males and one female, aged from 32 to 66 years (mean 56 yrs). The period between craniotomy and development of CSH ranged from 3 to 5 months (mean 4.3 mos). Postoperative hematomas were located on the operative sides in three patients and the contralateral side in the other. Early postoperative computed tomographic scans found subdural fluid collection in all patients. Magnetic resonance images showed linear meningeal enhancement in all patients. Postoperative CSH may be caused by mixture of blood in subdural cerebrospinal fluid collection which persists due to reduced brain elasticity and wide subarachnoid membrane opening resulting in neomembrane formation and finally development of hematoma.

Clinical analysis of nineteen patients with traumatic subdural hygromas.

Nineteen patients with traumatic subdural hygroma (TSH) who were admitted between 1988 and 1992, were reviewed. Diagnosis of TSH was made by serial computerized tomography (CT) after initial head injury, and patients were followed for up to 19 months after head injury. The patients ranged in age from 53 to 91 years (mean 75.6 yrs). Fifteen patients were treated conservatively, and 4 patients underwent surgery. Patients had disturbance of consciousness (transient in 5 cases, persisting in 3 cases), headache (10 cases), vomiting (6 cases), and vertigo (2 cases). TSH began to develop within 24 hs in 10 patients after initial head injury, and in 13 (68%) of 19 patients, TSH was demonstrated within 72 hs after the initial head injury. Chronic subdural hematoma (CSH) developed in 5 (26%) of 19 patients and 2 patients underwent surgery. In 15 patients, who were treated conservatively, TSH disappeared in 10 patients, and decreased in 4 patients, but remained unchanged in 1 patient. Clinically, 11 patients improved. Three patients remained unchanged. One patient, who had cerebral contusion, died of pneumonia. In 4 patients, who underwent surgery, including 2 patients with CSH, TSH disappeared in all patients. Two patients improved, and 1 patient was unchanged. Another patient, who had cerebral contusion and normal pressure hydrocephalus, died. In general, clinical outcome was satisfactory, except for the patients who had accompanying parenchymal lesions before or after head injury. Surgical treatment was limited to the patients who had rapidly enlarging TSH and neurological deterioration.