A SHORT OVERVIEW OF THE ESNR HISTORY
European Society of Neuroradiology
Diagnostic and Interventional
I joined the ESNR in 1973, presented by Jean-Paul Braun, the society’s co-founder with Auguste Wackenheim, and then Secretary General and subsequently President from 1990 to 1993. At the time, it was important to be an ESNR member, namely because it signified recognition of being a neuroradiologist. Five key issues have had a major impact on the activity and the very existence of the ESNR and neuroradiology in general, and have yet to be resolved:
First problem: what is neuroradiology?
Second problem: who is a neuroradiologist ?
Third problem: what training should neuroradiologists have?
Fourth problem: what are neuroradiology’s relations with allied disciplines?
Fifth problem: what is the ESNR’s role in Europe?
What is Neuroradiology?
For us, neuroradiology was a new discipline fully entitled to be included among the branches of medicine. This was to require a specialization qualification in neuroradiology but certification was only instituted in Portugal and not in other countries in Europe or elsewhere. I recall that Dr Ivan Moseley, a leading figure in British (neuro)radiology, claimed neuroradiology was the radiology discipline of a neurological hospital. In addition, there was much confusion in the past over the concept of discipline and its relative techniques. Neuroradiology cannot be considered merely a set of techniques, but a discipline with clinical and technical, diagnostic and therapeutic applications. In the seventies, many neuroradiologists thought that neuroradiology had died with the demise of pneumoencephalography and the advent of CT – not to mention MR, whereas these techniques have boosted the capabilities of the discipline going from morphological analysis to physiological and functional neuroradiology.
It was only during a seminar held in Toulouse in 2000 under Claude Manelfe’s presidency that I managed to convince my colleagues that neuroradiology is the discipline devoted to the diagnostic study and therapeutic management of the central nervous system and its structures using radiological techniques. Neuroradiology will therefore live as long as there is a need to investigate the central nervous system. Nowadays this concept is plain and widely accepted. Neuroradiology is currently considered a radiological super specialty also in legal terms. It is hoped that the specific indications of the European Society of Radiology will soon be implemented worldwide with five years of study (3+2), the last two devoted to the super specialty chosen by the student. On the one hand, this outcome is the result of the “diplomatic” work of the ESNR executive liaising with the ESR; on the other it is the cultural evolution of radiology that has started to grasp the need for a clinical approach, the long-standing preserve of neuroradiologists, and to make room for super specialties by renouncing radiology’s “know-it-all” attitude of the past.
Part of this work focused on relations with the European Union of Medical Specialists (UEMS) for recognition of the neuroradiology discipline. Under the forthright leadership of ESNR President Pierre Lasjaunias, the ESNR set up a study group that spent several years drafting the documentation required for this task. About five years ago, the UEMS finally attributed neuroradiology the role of a “division” of the radiology specialty. So a specific working group was set up comprising two representatives for each member state of the European Union presided over by Prof. Olof Flodmark, ESNR Past President and key member of the ESNR study group. Flodmark initially tackled the problem of training interventional neuroradiologists, a role other specialities close and not so close to neuroradiology were keen to appropriate. Flodmark devised an excellent training protocol that is about to be proposed to the EU member states. He is now working on the problem of training neuroradiologists in general, to be submitted to the member states for approval in the near future. This is a mammoth task that has involved generations of European neuroradiologists whose commitment merits the recognition and gratitude of us all.
Who is a Neuroradiologist?
It is to the great merit of Giovanni Ruggiero that Italy officially recognised neuroradiology with insertion of the discipline into the hospital legislation passed in 1969. This led to the institution of Neuroradiology Services that have increased from the original three to the 80 units working today. Recognition of the role and expertise of the “neuroradiologist” was based on a six-month internship and at least five years’ work in a specialist ward.
For these reasons enrolment in scientific societies was important at that time: to be accepted as members of the ESNR or AINR it was necessary to provide proof of working as a nervous system radiologist. This requirement has since been overcome, but it was only in 2000 that the ESNR welcomed as members anyone “with a scientific interest in neuroradiology irrespective of their specific activity”. In addition, it was only in 2010 that applicants not resident in Europe and their scientific societies were allowed to become ESNR Full Members. This enlargement reflects the evolution of the ESNR into a more open society based on its ever-increasing self-confidence. The number of ESNR members has grown from 80 in 1973 to more than a thousand today.
Since time immemorial, we have all become neuroradiologists by practising our craft in the workshop like any artisan. Now the specialization in radiology has become compulsory but official certification of the further qualification is still lacking. It exists in the United States and there are some master degree courses in European countries like Germany and Sweden, but there is no real coordination
In 1982 Pierre Lasjaunias proposed the institution of a European Neuroradiology Training Course on a par with the European Neurosurgical Training Course. Fed up with the insistent requests of the then very young Lasjaunias, President Wackenheim authorized him to set up a three-week course spread over three years. The course was a resounding success attracting participants from all over the world and attended by thousands students. The course was recently transformed into four weeks spread over two years with a final examination to qualify as a “Fellow in Neuroradiology”, the ESNR’s recognition of students’ neuroradiology expertise similar to the society’s admission criteria in the past but much more structured and important. My friendly acknowledgment to Charles Romanowski for he’s efforts in organizing the examinations. During my Presidency, 2008-2010, I set up the ESONR – European School of Neuroradiology that organizes advanced courses of higher qualification in diagnostic, paediatric, spinal and endovascular interventional neuroradiology. These courses are open to neuroradiologists certified as Fellows in Neuroradiology and offer a further qualification after sitting a specific examination. Special attention has been given to interventional neuroradiology courses, by Serge Bracard, Michael Söderman and Mario Muto. As a scientific society the ESNR provides a full training programme flanked by its first-rate scientific activity reflected in the annual ESNR meeting.
Certification has always been the primary objective of all ESNR Presidents and Officers. The reasons for failure are many and include the hostility of radiology and little or no help on the part of neurology and neurosurgery. The enormous development of neuroradiology in diagnostics and research, especially since the advent of functional magnetic resonance, has attracted the interest of myriad neurological, physiological and psychological disciplines: an important factor underpinning the creation of interdisciplinary relations, and certainly not the “alienation” of resonance to our competitors. Likewise, the development of endovascular interventional neuroradiology has created major problems with neurosurgery that in many countries has succeeded in taking over the techniques developed by neuroradiologists. Here I emphasize the fact that endovascular interventional neuroradiology has been a valuable European asset from René Djindjian to Guido Guglielmi, Pierre Lasjaunias, Luc Picard and many others. This has ensured that this activity remains almost completely within neuroradiology. Obviously teamwork with neurosurgeons is vital, and is maintained and developed by two highly complementary disciplines.
In this area, the ESNR has played a decisive role for more than twenty years not only from the “political” standpoint, but also due to its scientific and cultural impact with the active participation of all its members. The name of the ESNR was modified a few years ago adding “Diagnostic and Interventional” to highlight the bond between the two branches of neuroradiology that have diversified over the years but continue to remain complementary and culturally and operatively inseparable.
ESNR’s role in Europe
A fundamental issue has always been the representation of all European neuroradiologists seemingly in competition with the national societies that have been an ongoing reference point. In its early years, the ESNR was imbued with a post-war vision of a possible European nation state in which all members participated on an equal footing. I passionately embraced this ideal as did so many other members, namely the Presidents and Officers that have held office in the ESNR’s 43 years of life. Unfortunately, this ideal has waned in recent years with national interests undermining the European political edifice and this has also been reflected in the ESNR. For this reason, I included the enrolment of national scientific societies in the new ESNR constitution drafted in 2010, inviting them all not to be afraid of the idea of Europe.
I also recall that when it was founded the ESNR had a Council of Delegates, one for each nation, elected by its local members. The Council has changed over time to accommodate the national scientific societies and giving them the task of electing their own delegates. To start with, the Council meeting was confined to a dinner during the ESNR congress, but in 1993 under Salvolini’s presidency the meeting of delegates was given much more importance allotting a whole day before the start of the congress. The meeting was subsequently shortened but still kept separate from the ESNR congress.
The entry of national societies into the ESNR should make the Council of Delegates more complete. The creation of the Division of Neuroradiology within the UEMS has led to misunderstandings that have hampered its collaboration with the ESNR: the Division represents all neuroradiologists in the European Union whereas the ESNR represents only its own members but it spans all European nations including those outside the EU. In addition, enrolment of national societies should allow the ESNR to become more fully representative in the long term. The two sectors of the ESNR and the UEMS are strongly complementary and this must be a matter of the utmost attention: it would be disappointing if this misunderstanding were to spread to the ESNR executive committee. From the outset, the ESNR has been an important vehicle for meeting people and making friends: whatever nation s/he belongs to, no European is a foreigner in Europe!
Many efforts have focused on giving the ESNR an organizational structure that is now almost complete with the society’s new website. Many problems and numerous difficulties had to be overcome. We have devised rules for the organization of congresses and courses, the secretariat, elections, etc. This process is reflected in the ongoing review of the ESNR Constitution undertaken many times with the intent to make the ESNR ever more able to tackle the problems typical of a medium-size scientific society working in a very difficult sector and lacking the concrete foundations that only a specialization certification can provide.
This brings me to comment on some of the recurrent criticism raised against the ESNR as an elitist society or club. When the ESNR was founded in 1969 it could definitely be called a club, with a handful of members sharing an ideal, snubbed by national societies and generally misunderstood. A quantum leap has occurred since then to arrive at the present constitution, with national societies invited to join as institutional members, and they have. This was first advocated in a seminar held in Milan in 1994 and rejected by the national societies. It has taken nearly twenty years! Not just twenty years, but twenty years of hard work and planning. The definition of an elitist society implies the exclusion of large numbers of people. I don’t think this has ever been the case: the ESNR has developed gradually by progressive enlargement and has never excluded anyone from participating in the life and decision-making of the society. It is true that the ESNR has been run by an élite. But this is quite normal. By definition, the President and the Officers are representatives of the ESNR and are the society’s élite: an élite working for the society like a locomotive pulling a train. Founding members Wackenheim, Braun & Co. were an élite as are Parizel, Tali & Co and this will obviously be the case in the future. It is up to the society as a whole to candidate, vote and choose the best of its members (élite) to run the organization. This is the normal state of affairs in any association.
This short overview of the ESNR serves to highlight the milestones in the development of our scientific society, a development I was privileged to witness throughout almost its entire history. For almost 40 years ESNR has been one of the most important part of my life. In 43 years the ESNR has burgeoned from a tiny association of idealists into a strong and important association of highly specialized professional neuroradiologists recognized as such the world over. It has evolved gradually over time, tirelessly overcoming difficulties, misunderstandings and obstacles. Everyone has played a part from the ESNR members to the various Presidents and Officers. The society has seen great continuity: today’s ESNR was not founded yesterday and it is not the outcome of the latest attempts to salvage the society from errors of the past. We are a strong and lively scientific society thanks to the generous ongoing commitment of all those who have supported the ESNR from 1969 to date.
My period of office as ESNR Past President has come to an end. I have tried to perform my duties to the best of my ability, ever ready to lend a hand but trying not to be a “Past-President-Mother-in-Law”! I send all my colleagues, in particular the Presidents and Council members, my sincere good wishes for their future work.
Marco Leonardi, MD 24th September 2012
Professor of Neuroradiology
IRCCS Neurological Sciences, Bologna University
European Society of Neuroradiology:
Head of the Technical Committee, 1987-1990;
Head of the Advisory Board, 1990-1993;
Secretary General from 1993 - 2006.
President, 2008 – 2010;
President of the ESNR Congress, Udine 1987;
President of the ESNR Course, Bologna 1998;
President of the WFITN - World Congress of Interventional Neuroradiology, Venice 2005;
President of the Symposium Neuroradiologicum, World Congress of Neuroradiology, Bologna 2010.