Neuroradiology 2, 63-64 (1971) © by Springer-Verlag 1971

EDITORIAL The Past and Future of Neuroradiology as a Part of Neurological Sciences JAN JII~OUT, At present, Neuroradiology constitutes an essential part of the diagnostic procedures in neurology and especially in neurosurgery. Its results are continuously being confronted with those of other diagnostic methods, such as the clinical examination, electroencephalography, electromyography, biochemical investigations etc. In the relations between the Neurological Sciences and Neuroradiology this confrontation has always been one of the main factors which has stimulated the development of Neuroradiology. I t determined the trend of its research and the course of its progress. Time was when the results of the neuroradiological examination served mostly to confirm the clinical findings in many instances. This was when the clinical neurological examination was carried into the most minute details and in experienced hands yielded informarion of astounding reliability. On the contrary, the X-ray examination of that period stood at the beginning of its history and it was in many respects inadequate to match the accuracy of neurological findings. Moreover, the detailed neurological examination detected pathological changes in a very early stage of the disease. This most important time factor has been of primary importance in view of the necessity of early diagnosis and treatment of neoplasms. During this period the accuracy and timing of the results of the roentgen examination could not be compared with those of the clinical examination. In succeeding decades, owing to rapid technical progress and to the accumulation of experience the standing of Neuroradiology gained ground considerably. In comparison with the clinical neurological examination, what has been perhaps most appreciated has been that the answers that Neuroradiology gave in many situations has been relatively very reliable. It should be stressed that reliable negative findings also have their place in a complicated diagnostic situation as much as positive findings. This reliability surpassed that of neurological findings. Furthermore, the specificity of roentgen findings has been greater than that of the clinical symptoms, which in many eases represented only the effect of a non-specific reaction of the central nervous system to a lesion of diverse aetiology. For instance, on the basis of clinical neurological symptoms of focal brain damage it was difficult in many instances to decide whether the lesion was of a degenerative, vascular or neoplastic nature. Neuroradiology, however, gave a definite answer in most of these cases. Neuroradiology, Vol. 2

Prague

At present, the diagnostic possibilities of X ray in neurology are exploited to best advantage whenever they are applied to problems in which the clinical examination was found inadequate to yield conclusive information. At the same time, however, the possibilities and merits of the clinical examination should be constantly taken into consideration. Nor should it be forgotten that there exist cases with a clear-cut clinical picture and inconclusive X ray findings. The quickest way to diagnosis and treatment should be decided upon without awaiting the development of roentgen signs. Moreover, it should be remembered that in the detection of the earliest signs of damage to the central nervous system the clinical features still remain unparalleled. In the future, Neuroradiology should therefore concentrate mostly on earliest possible detection of pathological conditions, so as to match tim early appearance of clinical neurological signs. This is especially desirable with tumours where this would much enhance the outlook for successful treatment. One may confidently expect that pneumotomography, serioangiography with subtraction and magnification and cerebral scintigraphy will play a decisive role in promoting this development. In planning the progress in Neuroradiology the development and the present status of clinical neurology should also be considered. In consequence of considerable improvements in the organisation of care of neurological patients, they are directed to the departments of neurology at an earlier stage of the disease than previously. The result of this is that the object of X ray examination has shifted to more recent phases of the illness. Therefore, the classical clear-cut neuroradiological symptoms and syndromes are far less frequent, in fact, some of them now belong to the past. This trend can he, without doubt, expected to continue. Thus, only those X ray findings will be adequate and fully appreciated which help to detect and specify various conditions at this stage. Even in the future it can be expected that in many instances the reliable interpretation of X ray pictures will require a simultaneous consideration of neurological and radiological data. The number of situations in which a definite diagnosis would be arrived at only by this confrontation will steadily increase. There is no danger of neuroradiology being scotomised by neurological symptoms. On the contrary, he has to plan the examination accordingly and hl the interpretation of 5

64

Editorial

the findings he can but benefit from a synthesis of clinical and X ray findings. In this connection the respective role of Neuroradiology in neurology and in neurosurgery may be commented upon. At present, patients amenable to surgery have mostly benefited from the radiological findings as Neuroradiology has been concerned primarily with eases of surgical neurology. These patients constitute however, only a relatively small part of the bulk of neurological patients. The majority of these patients do not belong to the area of present focus of attention of neuroradiologists. It is the neurologists responsibility to make the differential diagnosis and to select the patients amenable to surgery from the majority of those who require conservative treatment. This procedure usually lies outside the scope of the neurosurgeon, who in consequence either of his surgical training or of many years of dealing with only a selected group of patients will be unable to diagnose reliably the majority of nonsurgical conditions. Nor is the time available in a busy neurosurgical department for lengthy examination and follow-up of these patients. The task of the neuroradiologist in this field of clinical neurology is of primary importance. There is the very greatest need for his specialised services. The demand particularly for the early detection of an operable condition and the early differentiation between the surgical and non-surgical ease is urgent. Finally, the large group of patients harboring various pathological conditions of the vertebral column should be mentioned. The number of these patients

who belong to the borderland of neurology and orthopedics, surpasses by far the number with brain turnouts or operable vascular lesions. These patients demand our help and they cannot be ignored. Here belong those frequent eases who can benefit from expert manipulative treatment. They, unable to obtain help within the sphere of school medicine, were frequently diverted into the hands of lay therapists. This field did not attract, up to now, the attention of the neuroradiologist to the degree that would correspond to the frequency and social importance of these conditions. Hitherto, radiology has been concerned mostly with the detection of bony reactions associated with the pathology of ligamentous structures or with detecting skeletal changes which would present a contraindication to manipulation. Nor did radiology do anything to promote the diagnosis of disorders of ligamentous spinal structures and to introduce an objective and scientific approach into this field of medicine. To develop the radiological diagnosis that would serve as a reliable base for planning the treatment of these disorders of the spine is another challenge to the neuroradiologist of the future. In summary, it can be expected that the standing of Neuroradiology within the field of the Neurological Sciences will gain continuously in importance, especially if most attention is paid to the initial manifestations of pathological conditions. Furthermore, a serious endeavor should be made to master the X ray diagnosis of the majority of neurological patients who require conservative therapeutic measures.