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| Year : 2000 | Volume
: 48
| Issue : 4 | Page : 319-21 |
Omental transplantation for Alzheimer's disease.
Rafael H, Mego R, Moromizato P, Espinoza M
Departments of Neurosurgery, General Surgery and Anesthesiology, Universidad Nacional Autonoma deMexico(UNAM), Mexico City, Mexico.
Correspondence Address:
Departments of Neurosurgery, General Surgery and Anesthesiology, Universidad Nacional Autonoma deMexico(UNAM), Mexico City, Mexico.
The acetylcholine, dopamine, serotonin and other neurotransmitters may be reduced in the subcommissural regions even in the early stages of Alzheimer's disease(AD), due to hypoperfusion of the anterior perforating and anterior choroidal arteries. This hypothesis was confirmed after the transplant of omental tissue on the optic chiasma, carotid crotch and anterior perforated space in a woman with moderate AD. Neurological improvement was better in the first week after the surgery than in the following months.
How to cite this article:
Rafael H, Mego R, Moromizato P, Espinoza M. Omental transplantation for Alzheimer's disease. Neurol India 2000;48:319 |
Alzheimer's disease (AD) is a disorder characterised by a progressive dementia, where cause is largely unknown. However, progress has been made in recent years regarding its aetiology[1],[2] and surgical treatment.[3],[4] Based on our clinical experience with omental transplantation to the encephalon in patients with ischaemic infarcts,[5] we subjected a woman with AD to transplants of omental tissue in the region of optic chiasma and anterior perforated space (APS), for increasing the revascularisation of the cholinergic nuclei.
A 53 year old right-handed woman presented with progresssive worsening of recent memory since October 1992. Seven months later, she developed olfactory and gustatory deficit. This was followed, two years later, by progressive deterioration of cognitive and behavioral functions characterized by depression, obsessive ideas, hallucinations, right-left confusion and impaired activities of daily living. The onset of these symptoms was insidious and course undulating (periods of clinical improvement alternated with those of worsening) and progressive. There was no family history of AD.
The examination revealed anosmia, moderate global dysphasia, apraxia, agnosia, lack of attention, generalised rigidity, postural changes and gait disturbances. Preoperative CT scans showed: i) atherosclerosis of the supraclinoid portion of the internal carotid arteries; ii) atherosclerosis of the circle of Willis [Figure. 1a]; iii) moderate diffuse cortical atrophy; iv) hypotrophy of the subcommissural regions and v) moderate dilatation of the ventricular system.
Operation : With the clinical diagnosis of moderate AD,[2],[6] an omental transplantation was performed on 20th October 1998, without complications. Carotid bifurcation and the APS were located through a left pterional-transsylvian approach.[7],[8] During the surgery we found: i) cerebral cortex atrophy; ii) moderate atherosclerosis of the supraclinoid portion of the internal carotid artery and its terminal branches; iii) four exsanguinated and collapsed anterior perforating arteries arising from the carotid crotch and iv) some perforating branches with residual blood flow centripetal to the origin of the vessels. The omental tissue was placed on the optic chiasma, carotid bifurcation and APS.
Postoperative course : Subjective and objective clinical improvement started on the third day after surgery. Her facial expression and the smell improved by 50 percent. After 15 days, smell, taste, posture and her walk were almost normal. Moreover, she experienced relief from her symptoms of recent memory and specific cognitive dysfunction. Postoperative CT scans (November 24, 1998) showed omentum over left sphenoidal ridge, optic chiasma and APS [Figure. 1b], along with revascularisation of the nervous tissue surrounding the omentum. 12 months postoperative, she had only slight to moderate deterioration of her specific cognitive functions and was capable of undertaking some activities of daily living.
These results demonstrate that omental transplantation on the optic chiasma, carotid bifurcation and APS can improve symptoms of AD, according to the clinical stage of the illness.[2] Our first patient, a 75 year old woman with initial and mild AD (characterised by recent memory and cognitive impairment, associated with the loss of smell and taste) at present is symptom free 17 months after the operation,[8],[9] and can effect activities of daily living. In a clinical study of 60 AD patients,[2] mild AD was seen in 19, moderate in 30 and advanced AD in 11 cases. In all cases with mild AD, CT scans was normal or there was normal for the age cerebral atrophy. By contrast, in moderate or advanced stages there was moderate to severe diffuse cerebral atrophy, associated with dilatation of the ventricular system.
The omental tissue placed on these surgical regions, promotes the neoformation of blood vessels over underlying and adjacent nervous tissue and, through these vascular connections, the subcommissural regions and medial temporal lobes[2],[8] receive an increase in blood flow, oxygen, neurotransmitters (dopamine, noradrenaline and acetylcholine) and neurotrophic factors.[5],[10] That is, with this surgical technique we can improve the function of the residual nervous tissue in ischaemic area and ischaemic penumbra. This may remotely suggest neuronal regeneration.[2],[8],[9]
In conclusion, unlike the other surgical techniques[3],[4] where omentum was directly placed upon the cerebral cortex by omental transposition, our surgical procedure improves the hypoperfusion and hypometabolism[2],[8] of the brain parenchyma, irrigated by the anterior perforating and anterior choroidal arteries.
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| 2. | Rafael H, Mego R, Cortes R : Enfermedad de Alzheimer : Una correlacion entre la etapa tempranay aterosclerosis del pollgono de Willis. Climaterio 2000 (in press). |
| 3. | Goldsmith HS : Omental transposition for Alzheimer's disease. Neurol Res 1996; 18 : 103-108. |
| 4. | Liu XH, Zou XW : Two cases of Alzheimer's disease treated by great omentum transplantation. Presented at the First International Congress of Omentum in CNS. Xuzhou, China. 1995; 36 : 7-11. |
| 5. | Rafael H : El epiplon : Trasplante al sistema nervioso. Mexico DF : Editorial Prado 1996; 1-171. |
| 6. | McKhann G, Drachman D, Folstein M et al : Clinical diagnosis of Alzheimer's disease : Report of the NINCDS-ADRDA work group under the auspices of department of health and human services task force on Alzheimer's disease. Neurology 1984; 34 : 939-944. |
| 7. | Rafael H : Transsylvian and transinsular approach. Turk Neurosurg 1995; 5 : 53-56. |
| 8. | Rafael H, Mego R : Omental transposition. Surg Neurol1999. |
| 9. | Rafael H, Mego R : Ablative surgery and deep brain stimulation for Parkinson's disease. Neurosurgery1999; 45 : 199-200 . |
| 10. | Goldsmith HS : The omentum : Research and clinical applications. Springer-Verlag New York. 1990; 5-245. |
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