Abstracts

Rationale: An estimated 100,000 patients are eligible for epilepsy surgery in the United States. In controlled trials, ablative surgery has been shown to be superior to medical therapy. In ideal patients seizure free outcome can be as high as 80% to 90%. However, despite these numbers there is question of whether epilepsy surgery should be performed in people with significant, chronic, medical conditions such as liver transplantation. There were more than 6,300 liver transplants performed in 2008. Five year survival following liver transplantation is 72%. Methods: We present three people who first underwent liver transplantation and years later had a temporal lobectomy. Results: Patient #1 had neonatal hepatitis at age 6 weeks, which led to a liver transplantation at age 4. She was treated with OKT3 which resulted in status epilepticus. She developed mild developmental delay and obsessive compulsive disorder and seizures. Prior to surgery she had complex partial seizures every two weeks. At age 25, she had a right temporal lobectomy. On pathology she had mesial temporal sclerosis. After discharge she became seizure free for two years. Patient #2 began having rare complex partial seizures at the age of 7. In adulthood they gradually accelerated and usually secondarily generalized. She would have 5 - 8 seizures a month. An MRI at age 40 showed a left temporal lobe lesion. She had a lesionectomy and a ganglioglioma was found. Her seizure frequency did not change after this procedure. She developed autoimmune hepatitis at age 50 which led to a liver transplantation. At age 57, she had further resection with a left anterior temporal lobectomy. This resulted in an improvement with her experiencing only nocturnal generalized seizures, 1 per month. Medication adjustments were done with her anti-convulsants and prednisone and she has been seizure free for 6 months. Patient #3 began having rare complex partial seizures at age 10. At age 47 he had liver transplantation for hepatitis B. In the 15 years of follow-up he had no recurrence of hepatitis or significant liver rejection. His epilepsy became pharmacologically intractable, experiencing 1 seizure per week. He underwent a right temporal lobectomy at age 55. Hippocampal sclerosis was found on pathology. In the 6 years following his ablative brain surgery he has had multiple simple partial seizures but only a single complex partial seizure. Conclusions: In patients without significant pre-existing medical conditions the literature strongly supports ablative epilepsy surgery in appropriate candidates. Since liver transplantation is not a rare procedure, we expect that there will be patients with pre-existing liver transplantation who may also be excellent candidates for an epilepsy surgery evaluation. Liver transplantation has good long term survival and should not necessarily be a contraindication. We have successfully performed ablative surgery in three patients with prior liver transplantation. We have allowed these patients to take advantage of two surgical procedures which independently have an excellent success rate.