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 »  Abstract
 »  Introduction
 »  Case report
 »  Results
 »  Discussion
 »  Conclusion
 »  References

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Year : 2002  |  Volume : 50  |  Issue : 1  |  Page : 71-4

Omental transplantation for temporal lobe epilepsy : report of two cases.


Department of Neurosurgery, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico.

Correspondence Address:
Department of Neurosurgery, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico.
yasherma@mailcity.com

  »  Abstract

The authors present two patients, with poorly controlled temporal lobe epilepsy, who received transplants of omental tissue on the anterior perforated space and left temporal lobe. At present, 26 months after the operation, the first patient has improved about 85 percent; whereas the second patient has complete control of seizures nine months after the operation. These clinical results indicate that epileptic seizures can be reduced or aborted with this new surgical modality (reconstructive technique).

How to cite this article:
Rafael H, Mego R, Moromizato P, Garcia W. Omental transplantation for temporal lobe epilepsy : report of two cases. Neurol India 2002;50:71


How to cite this URL:
Rafael H, Mego R, Moromizato P, Garcia W. Omental transplantation for temporal lobe epilepsy : report of two cases. Neurol India [serial online] 2002 [cited 2020 Mar 28];50:71. Available from: http://www.neurologyindia.com/text.asp?2002/50/1/71/1358




   »   Introduction Top

The epilepsy surgery began in 1886, when Victor Horsley treated three patients with refractory seizures by surgical ablation of the epileptogenic zone.[1] Since then and upto now, three essential procedures are used at many neurosurgical centers[2-4]: i) surgical ablation, ii) disconnection procedures and iii) vagus nerve stimulation (palliative technique).
However, since May 6, 1988 the authors have used a new surgical technique for patients with ischemic infarct and epilepsy.[5],[6] Two patients with poorly controlled epileptic seizures and treated by transplants of omental tissue on the epileptogenic zone are presented.


   »   Case report Top

Case 1: A 33 year old right handed woman, had a 21 year history of medically refractory epilepsy. During these years, she had been treated with several antiepileptic drugs. Since 1995, she had received clonazepam 5 mg/day and oxcarbazepine 1200 to 1500 mg/day. During the last 3 years she had three spontaneous abortions between 6 to 13 weeks of pregnancy.
During seizures she had tonic flexion of her right hand, palpitation, motor dysphasia and paleness, associated with partial impairment of consciousness for several seconds, and with a frequency of about 20 episodes per month. She also had 2-3 generalized tonic-clonic seizures per month, especially during the menstrual period. Postictally, she had moderate global dysphasia, memory impairment and headache for 30 to 60 minutes. In the interictal period, she had episodes of headache, irritability, motor dysphasia, sleep disorders and impairment of recent memory.
Neurological examination revealed normal motor and sensory functions. Neuropsychological testing showed essentially recent memory impairment, slight motor dysphasia, irritability and agitation. Extracranial interictal electroencephalogram showed well localized epileptiform discharges in the left temporal region and, occasionally, generalized atypical spikes. A preoperative computerized tomography (CT) scan showed severe atrophy in both temporal lobes, especially in the left medial temporal lobe and probable heterotopia or sclerosis in a small area of the left temporo-occipital cortex. The clinical pre and postoperative picture was recorded on video tape, and the surgery was performed on April 18,1998 without complications.
Case 2: A 33 year old right handed man was admitted to hospital epileptic seizures, sleep disorders and progressive impairment of recent memory. During the last 28 years, he had been treated with many antiepileptic medicaments. Since 1997, he had received clonazepam 5 mg/day and sodium valproate 520 mg/day. He had olfactory hallucinations, palpitations, paleness, stuttering and partial impairment of consciousness for few seconds, with a frequency of about 12 episodes per month. He had 0-2 generalized tonic-clonic seizures per month. Postictally, he had moderate global dysphasia, memory impairment, headache and sickness for about two hours. In the interictal period, he had episodes of headache, stuttering, sleep disorders and lately, impairment of recent memory.
Neuropsychological testing revealed frequent stuttering, agitation, anxiety and recent memory impairment. An interictal electroencephalogram revealed epileptiform discharges, most pronounced at the left temporal lobe. A preoperative CT scan showed moderate atrophy in both the temporal lobes, especially in the anteromedial portion of the left temporal lobe [Figure1]. Surgery was carried out on September 7, 1999.
Surgical Procedure: With the diagnosis of complex partial seizures with or without generalized tonic-
clonic seizures,[7] due to a principal lesion in the medial temporal lobe, omental tissue (free omental flap with vascular microanastomosis) was transplanted on the anterior perforated space (APS) and left temporal lobe.[8],[9] An omental segment was placed on the APS (posterior and lateral zone) and medial surface of the left temporal lobe and another omental segment on the inferior and lateral surface of the same temporal lobe.


   »   Results Top

In both patients, recent memory and sleep disorders improvement occurred on the third day after surgery. By June 2000, the first patient was having between 0-4 preictal seizures per month (earlier 20 months) and only five generalized tonic-clonic seizures during these 26 months postoperative (earlier 2-3 months). She is on clonazepam 3 mg in the night and oxcarbazepine 600 mg/day. During this postoperative course, the seizure occurred more frequently in the first few months; the severity and duration of epileptic attacks still being less than that before surgery. Moreover, in the intervening period, she had a pregnancy and normal delivery. Her postoperative CT scans (June 1,1999) showed the omental tissue on the medial and lateral surface of the left temporal lobe, as well as revascularization of the underlying cerebral parenchyma.
The second patient, 9 months postoperative, had 80% improvement in stuttering. He was getting only clonazepam 2 mg at night. His postoperative CT scans (September 12, 1999) showed the omentum on the medial and lateral surface of the left temporal lobe as well as revascularization of the underlying brain [Figure 2]. During the nine months after the operation, this surgical technique led to a complete control of seizures.


   »   Discussion Top

These results demonstrate that placing omental tissue directly upon the epileptic focus (medial temporal lobe structures) and neighbouring areas (posterior hypothalamus, subcommissural region and extreme superior of mesencephalic reticular nucleus), can reduce or abort complex partial seizures and confirm our previous clinical experiences[5],[6] as well as of other authors.[10] The omentum[11],[12] is used because it is the best tissue to provoke the neoformation of blood vessels (revascularization) and through these vessels, the underlying and adjacent brain receives an increase in blood flow, oxygen, omental neurotransmitters (dopamine, noradrenaline and acetylcholine) and neurotrophic factors (nerve growth factor and gangliosides).
Thus, the functional recovery of neurons and axons in the epileptic foci (residual nervous tissue)[5],[6] in ischemic and ischemic penumbra region can improve, if the blood flow is increased or reinstituted through the omentum. Therefore, interictal hypoperfusion[13],[14] and hypometabolism[15] of the epileptic foci are normalized and likewise, extracellular concentration of glutamate and aspartate,[16] and the neuronal hyperexcitability are reduced.[13],[17]
Although pre and postoperatively regional cerebral blood flow was not measured by positron emission tomography (PET) or single photon emission computed tomography (SPECT) in the present two patients, the neurological improvement previously obtained after omental transplantation on the APS in patients with essential arterial hypertension,[18],[19] Alzheimer's disease,[20] and late sequelae of the basal ganglia, the internal capsule and the thalamus[8],[9],[12] demonstrate the efficacy of the transplanted omentum.
In the author's opinion, the success of the pregnancy in the first patient was also due to a functional recovery of the neuronal hyper-excitability[21-23] in the medial temporal lobe and its efferent projections via the fornix towards the neuroendocrine cells within the hypothalamus[23],[24] and subcommissural region.[20],[24]


   »   Conclusion Top

The present two patients demonstrate that interictal focus must be revascularized in order to revert to the progressive hypoperfusion and hypometabolism, which produces increased epileptogenicity. Likewise, the authors believe that by means of this surgical procedure (reconstructive technique), the neuronal loss and the astrocytic gliosis can be stopped.

 

  »   References Top

1.Horsley V: Brain surgery. BMJ 1886; 2: 670-675.  Back to cited text no. 1    
2.Penfield W: The radical treatment of traumatic epilepsy and its rationale. Can Med Assoc 1930; 23: 189-197.  Back to cited text no. 2    
3.The vagus nerve stimulation study group. A randomized controlled trial of the chronic vagus nerve stimulation for treatment of medically intractable seizures. Neurology 1995;45:224-230.   Back to cited text no. 3    
4.Queenan JV, Germano IM: Advances in the neurosurgical management of adult epilepsy. Contemp Neurosurg 1997;19: 1-6.  Back to cited text no. 4    
5.Rafael H: Commentary on human hippocampal structures. J Chil Neurol 1998; 13: 146-147.   Back to cited text no. 5    
6.Rafael H: Surgical and neurological complications in a series of 708 epilepsy surgical procedures. Neurosurgery 1998; 42: 675-676.   Back to cited text no. 6    
7.Commission on classification and terminology of the International League Against Epilepsy. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981; 22: 489-501.   Back to cited text no. 7    
8.Rafael H: Transsylvian and transinsular approach. Turk Neurosurg1995; 5: 53-56.   Back to cited text no. 8    
9.Rafael H, Moromizato P, del Angel J et al: Trasplante de epiplon para infarto isquemico del cerebro. Cir Ciruj (Mex) 1998; 66: 155-158.   Back to cited text no. 9    
10.May CH, Vogel Is: Epilepsia partialis continua successfully treated by transplantation of omentum: Case report. Presented at the First International Congress of Omentum in CNS. Xuzhou, China. 1995; 34-35.   Back to cited text no. 10    
11.Goldsmith HS: The omentum: research and clinical applications. Springer-Verlag, New York. 1990; 5-245.   Back to cited text no. 11    
12.Rafael H: El epiplon: Trasplante al sistema nervioso. Mexico, DF: Editorial Prado 1996; 1-171.   Back to cited text no. 12    
13.Weinand ME, Carter LP, El-Saadany WF et al: Cerebral blood flow and temporal lobe epileptogenicity. J Neurosurg 1997; 86: 226-232.   Back to cited text no. 13    
14.Rougier A, Lurton D, EI Bahh B et al: Bilateral decrease in interictal hippocampal blood flow in unilateral mesiotemporal epilepsy. J Neurosurg 1999; 90: 282-288.   Back to cited text no. 14    
15.Blum DE, Ehsan T, Dungan D et al: Bilateral temporal hypometabolism in epilepsy. Epilepsia 1998; 39: 651-659.   Back to cited text no. 15    
16.Benbeniste H, Drejer J, Schousboe A et al: Elevation of the extracellular concentration of glutamate and aspartate in rat hippocampus during transient cerebral ischemia monitored by intracerebral microdialysis. J Neurochem 1984; 43: 1369-1374.   Back to cited text no. 16    
17.Lopez E, Parra L, Bravo J et al: Cambios en la excitabilidad neuronal y alteraciones en la densidad neuronal del hipocampo inducidos por isquemia local. Arch Neuroscien (Mex) 1997; 2: 61-66.   Back to cited text no. 17    
18.Rafael H: Microvascular decompression of the left lateral medulla oblongata for severe refractory neurogenic hypertension. Neurosurgery 1999; 44: 691-692.   Back to cited text no. 18    
19.Rafael H: Hipertension arterial esencial: Un analisis neurologico sobre su etiologia. Hipertension (Mex) 2000; 20: 7-10.   Back to cited text no. 19    
20.Rafael H, Mego R, Moromizato P et al: Omental transplantation for Alzheimer's disease: case report. Neurol India 2000; 48: 319-321.   Back to cited text no. 20    
21.Logothetis J, Harner R: Electrocortical activitation by estrogens. Arch Neurol 1960; 3: 290-297.   Back to cited text no. 21    
22.Laplante P, Saint-Hilaire JM, Bouvier G: Headache as an epileptic manifestation. Neurology 1983; 33: 1493-1495.   Back to cited text no. 22    
23.Woolley CS: Structural and electrophysiological effects of estradiol may increase the likelihood of seizures. Epilepsia 1998; 39 (Suppl 6): 210-211.   Back to cited text no. 23    
24.Pfaff DW, McEwen BS: Actions of estrogens and progestins on the nerve cells. Science 1983; 219: 808-814.   Back to cited text no. 24    

 

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