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Omental Transplantation for Temporal Lobe Epilepsy :
Report of Two Cases
H. Rafael, R. Mego, P. Moromizato,* W. Garcia*
Universidad Nacional Autonoma de Mexico (UNAM) Departments of General Surgery and Anesthesiology* Instituto Mexicano Del Seguro Social (IMSS) 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).
Key words : Complex partial seizures, Epileptogenic zone, Omental transplantation.
controlled epileptic seizures and treated by transplantsof omental tissue on the epileptogenic zone are The epilepsy surgery began in 1886, when Victor Horsley treated three patients with refractory seizuresby surgical ablation of the epileptogenic zone.1 Since Case Report
then and upto now, three essential procedures are usedat many neurosurgical centers2-4 : i) surgical ablation, Case 1 : A 33 year old right handed woman, had a 21 ii) disconnection procedures and iii) vagus nerve year history of medically refractory epilepsy. During these years, she had been treated with severalantiepileptic drugs. Since 1995, she had received However, since May 6, 1988 the authors have used a clonazepam 5 mg/day and oxcarbazepine 1200 to new surgical technique for patients with ischemic 1500 mg/day. During the last 3 years she had three infarct and epilepsy.5,6 Two patients with poorly spontaneous abortions between 6 to 13 weeks ofpregnancy.
Correspondence to : Dr. H. Rafael, Belgica 411-BIS, ColoniaPortales, 03300 Mexico City, Mexico.
During seizures she had tonic flexion of her right hand, palpitation, motor dysphasia and paleness, Omental Transplantation in Intractable Epilepsy associated with partial impairment of consciousnessfor several seconds, and with a frequency of about 20episodes per month. She also had 2-3 generalizedtonic-clonic seizures per month, especially during themenstrual period. Postictally, she had moderate globaldysphasia, memory impairment and headache for 30to 60 minutes. In the interictal period, she hadepisodes of headache, irritability, motor dysphasia,sleep disorders and impairment of recent memory. Neurological examination revealed normal motor andsensory functions. Neuropsychological testingshowed essentially recent memory impairment, slightmotor dysphasia, Extracranial interictal electroencephalogram showedwell localized epileptiform discharges in the lefttemporal region and, occasionally, generalizedatypical spikes. A preoperative computerizedtomography (CT) scan showed severe atrophy in bothtemporal lobes, especially in the left medial temporallobe and probable heterotopia or sclerosis in a smallarea of the left temporo-occipital cortex. The clinicalpre and postoperative picture was recorded on videotape, and the surgery was performed on April 18,1998 Fig. 1 : Preoperative CT scan without contrast showing
moderate atrophy in the anteromedial surface of the lefttemporal lobe.
Case 2 : A 33 year old right handed man was admittedto hospital epileptic seizures, sleep disorders and clonic seizures,7 due to a principal lesion in the medial progressive impairment of recent memory. During the temporal lobe, omental tissue (free omental flap with last 28 years, he had been treated with many anti- vascular microanastomosis) was transplanted on the epileptic medicaments. Since 1997, he had received anterior perforated space (APS) and left temporal clonazepam 5 mg/day and sodium valproate 520 lobe.8,9 An omental segment was placed on the APS mg/day. He had olfactory hallucinations, palpitations, (posterior and lateral zone) and medial surface of the paleness, stuttering and partial impairment of left temporal lobe and another omental segment on the consciousness for few seconds, with a frequency of inferior and lateral surface of the same temporal lobe.
about 12 episodes per month. He had 0-2 generalizedtonic-clonic seizures per month. Postictally, he had moderate global dysphasia, memory impairment,headache and sickness for about two hours. In the In both patients, recent memory and sleep disorders interictal period, he had episodes of headache, improvement occurred on the third day after surgery.
stuttering, sleep disorders and lately, impairment of 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 Neuropsychological testing revealed frequent these 26 months postoperative (earlier 2-3 months).
stuttering, agitation, anxiety and recent memory She is on clonazepam 3 mg in the night and impairment. An interictal electroencephalogram oxcarbazepine 600 mg/day. During this postoperative revealed epileptiform discharges, most pronounced at course, the seizure occurred more frequently in the the left temporal lobe. A preoperative CT scan showed first few months; the severity and duration of epileptic moderate atrophy in both the temporal lobes, attacks still being less than that before surgery.
especially in the anteromedial portion of the left Moreover, in the intervening period, she had a temporal lobe (Fig. 1). Surgery was carried out on pregnancy and normal delivery. Her postoperative CT scans (June 1,1999) showed the omental tissue on themedial and lateral surface of the left temporal lobe, as Surgical Procedure : With the diagnosis of complex well as revascularization of the underlying cerebral partial seizures with or without generalized tonic- Thus, the functional recovery of neurons and axons inthe epileptic foci (residual nervous tissue)5,6 inischemic and ischemic penumbra region can improve,if the blood flow is increased or reinstituted throughthe omentum. Therefore, interictal hypoperfusion13,14and hypometabolism15 of the epileptic foci arenormalized and likewise, extracellular concentrationof glutamate and aspartate,16 and the neuronalhyperexcitability are reduced.13,17 Although pre and postoperatively regional cerebralblood flow was not measured by positron emissiontomography (PET) or single photon emissioncomputed tomography (SPECT) in the present twopatients, the neurological improvement previouslyobtained after omental transplantation on the APS inpatients with essential arterial hypertension,18,19Alzheimer’s disease,20 and late sequelae of the basalganglia, the internal capsule and the thalamus8,9,12demonstrate the efficacy of the transplanted omentum.
In the author’s opinion, the success of the pregnancyin the first patient was also due to a functional Fig. 2 : Postoperative CT scan with contrast obtained 5 days
recovery of the neuronal hyper-excitability21-23 in the after surgery, showing the omentum on the anteromedial and medial temporal lobe and its efferent projections via lateral surface as well as revascularization into the underlying the fornix towards the neuroendocrine cells within the hypothalamus23,24 and subcommissural region.20,24 The second patient, 9 months postoperative, had 80%improvement in stuttering. He was getting only Conclusion
clonazepam 2 mg at night. His postoperative CT scans(September 12, 1999) showed the omentum on the The present two patients demonstrate that interictal medial and lateral surface of the left temporal lobe as focus must be revascularized in order to revert to the well as revascularization of the underlying brain progressive hypoperfusion and hypometabolism, (Fig. 2). During the nine months after the operation, which produces increased epileptogenicity. Likewise, this surgical technique led to a complete control of the authors believe that by means of this surgical procedure (reconstructive technique), the neuronalloss and the astrocytic gliosis can be stopped. Discussion
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Accepted for publication : 9th August, 2001.
RESEARCH PROGRAMME OVERVIEW Attempts to Identify New Therapeutic Targets for Triple-Negative Breast Cancer Targeted therapy is currently available for the majority of patients with newly diagnosed breast cancer. Thus, patients with estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive disease receive hormone therapy, while patients with HER2-postive disease may be treat