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ORIGINAL ARTICLE

“A HISTORY OF TWENTIETH CENTURY NEURORADIOLOGY IN URUGUAY AND ITS FAR-REACHING INFLUENCE IN LATIN AMERICA”. Angélica Wozniak Eduardo Wilson

INTRODUCTION

When we were invited to describe Fischgold, around the middle of the the history of neuroradiology in twentieth century. (3) Uruguay for the Regional Erik Lindgren, who at a later date Conference of taking was likewise considered the father place in Montevideo in September of neuroradiology, wrote the chapter 2012, we made the project of writing entitled “History of Neuroradiology” on the subject. (1) We later wrote in “ of the Skull and this account that only includes the Brain”, the classic text of Newton events that took place during the and Potts. This book was published twentieth century. in 1971, just before Computerized Although the History of Tomography was discovered. neuroradiology is quite well known, Lindgren considers that a brief summary is mandatory. It neuroradiology came into being began with the discovery of X-rays when Dandy performed, in 1918, the by Roentgen in 1895. In 1896 a air injection that marked the Swedish , Dr. Stenbeck, beginning of took anterior-posterior and lateral pneumoencephalography. Lindgren views of the skull, which enabled considered that the preceding stage, him to detect a projectile in the which included pioneering occipital region. The patient was experiences, belonged to the operated because of that finding, general development of Radiology. and the location of the bullet was The use of contrast implied new confirmed. (2) advances; contrast was now Later on, several milestones marked injected into arteries. In 1927, Egas the development of neuroradiology. Moniz proposed a new method for An important one would be the the study of intracranial structures: visualization of a calcified pineal injection of a positive contrast agent gland by Schuller in 1906. On into the carotid artery. In this way account of this achievement, among cerebral angiography began, which other contributions to skull signified a huge advance in radiology, Schuller was considered neurological diagnosis. the father of neuroradiology by Many years later Computerized several authors like Bull and Tomography (CT) came along,

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allowing a direct vision of brain During the second stage, contrasted for the first time. We images of intracranial and spinal might say that Computerized canal structures are obtained. Tomography was the greatest These structures are the ventricles medical discovery of the twentieth and the subarachnoidal spaces, century. It brought about a which are evidenced by filling them revolution in medical knowledge. with air (pneumoencephalography, The leading player in this process pneumomyelography) or with was Sir Godfrey Hounsfield in 1972. positive contrast agents He received the Nobel Prize for (angiography). Alterations and shift and Physiology in 1979, of these structures lead to the along with Allen McCormack. detection of anomalies and their Later on Magnetic Resonance (RM) localization. was developed; it offered a more During the third stage, imaging of defined image, multiplanar brain parenchyma becomes acquisition, the possibility of possible (CT, MR) and now the functional imaging and topography and the nature of brain spectroscopy. Mathematicians, lesions can be pinpointed. physicists, engineers and During the fourth stage the all took part in its genesis, because possibility arises to define functional they developed concepts apparently brain alterations by imaging unrelated and with no immediate (functional neuroradiology). applicability, which were blended NEURORADIOLOGY IN together by their joint efforts, URUGUAY achieving a technique based on These stages will be our starting contributions from all those fields. points for this account of the history The first application of MR was of neuroradiology in Uruguay. spectroscopy, which was based on Evidently, as new techniques the same principles. Imaging itself, appear, they join the existing ones, that is to say MRI, was developed which also continue to develop and somewhat later. Many of the progress. scientists who in the course of Stage I: Bone Imaging of skull several years described these and spine. findings were awarded the Nobel A few weeks after X-rays were Prize. discovered, X-ray films were being The last acquisitions in the field of made in the “Río de la Plata” region functional imaging were: MR (4). One year later, in 1897, came spectroscopy, PET (positron the first request of a radiograph from emission tomography) and a physician. Photographs of interventional imaging (for vessels radiographs were included in and tumors). doctoral theses; the first of these We can identify several stages in was registered in 1899. The first the development of neurological radiograph of a patient to be diagnosis. published in a medical journal The first stage corresponds to bone appeared in the year 1900 (4). imaging of the skull and the spinal There was no Radiology Chair yet, column. Bone deformations, but there were X-ray rooms in some fractures and calcifications could be of the clinics at the Hospital de diagnosed. Caridad, with one physician taking responsibility for all studies,

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE

including radiographs of skull and He himself took the first radiographs spine. Equipments were scarce and ever to be published in theses and primitive, and they were chiefly used publications at the end of the for radioscopy. At the turn of the nineteenth century and the century there were X-ray beginning of the twentieth century. equipments in both the Hospital de Later on he became Professor of Caridad and some private practices. at the Faculty of First Augusto Turenne, then Medicine, Dean of the said Faculty Leopoldo Thévenin were the and first president of the physicians' physicians responsible for the X-ray union (Sindicato Médico del rooms at the hospital, until the Uruguay) (5). Radiology Institute was created in Leopoldo Thévenin (1878-1912): 1913. In addition, some private As soon as he graduated, on August medical practices had X-ray 12,1905, he went to France and equipments. there he decided to become a Augusto Turenne (1870-1948): He radiologist. He came back two years was the director of the first later, bringing X-ray equipment Radiology Laboratory, which was which he donated to the Hospital de created in 1899, as a development Caridad, in order to establish a of the Laboratory for Photography specialized department there. The and Microphotography at the new Radiology Department began Hospital de Caridad. Turenne to operate in 1908, under the supervised the work and attended direction of Thévenin. It preceded personally to the Radioscopy and the Radiology Institute. It was both a Microphotography sections. replacement and an improvement on the department managed by Turenne. By then, Turenne as a successful obstetrician had lost interest in Radiology (6). Stage II: contrasted imaging of intracranial and spinal structures We can identify two periods within this stage. In the first one we will remember the pioneers. In the second one we will review the advent and development of the School of neuroradiology of Montevideo and its far-reaching influence in Latin America. • The pioneers:

Figure 1.- Hydatid cyst of the brain. – These were radiologists who Ventriculography performed by Dr. worked, as a rule, side by side with Alejandro Schroeder by means of air surgeons and physicians. It fell to injection into the lateral ventricle and the surgeons and physicians to perform cyst. A cyst with neat contours is seen, the procedures on the patients, such markedly compressing the lateral as puncturing and injecting the ventricle and displacing the septum ventricles or the subarachnoid pellucidum towards the right. space, while it was the radiologist who took the radiographs, adjusting

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the position of the patient and injection of air or iodine contrast. choosing the technique These cases were published in 1939 (8,9). His coworker was Juan Cunha was perhaps the first radiologist Nicolás Caubarrere, the Uruguayan radiologist to take an successor of Cunha. After being interest in the diagnosis of appointed Professor and Director of neurological disorders. Having the Institute in 1937, graduated in 1913, Juan Cunha Schroeder incorporated showed an early interest for encephalographic studies to the Radiology. He was the radiologist of routine diagnostic procedures for the Neurology Institute since it was encephalic tumors and did likewise created in 1927. He performed the with myelography and the disorders first contrast studies at the Institute: of the spinal cord. myelographies in 1927 and 1928, as In May 1936, Eduardo Palma as well as the first neurosurgeon and Eugenio pneumoencephalography in March Zerboni as radiologist performed 1929. He was also the radiologist of the first cerebral angiography by the clinic of Professor Navarro and percutaneous carotid puncture, the director of the Radiology using Thorotrast as a contrast Department at the Hospital Pedro agent. It was communicated to the Visca. He was appointed Associate Medical Society of Montevideo on Professor of Radiology. After the its session on September 25, 1936 Radiotherapy Department was (10) (Fig. 2). transferred to its present facilities on Avenue 8 de octubre, he was Head of the Radiodiagnostics Department at the Hospital Maciel (formerly Hospital de Caridad). He died suddenly in 1938, in Buenos Aires, where he had gone to give a conference on hydatid cyst of the lung (5). Radiology of the nervous system was also done outside the Institute. Pedro Hormaeche, a general physician, had performed the first myelography with lipiodol in 1924. Juan César Mussio Fournier and Juan Malet were the first to publish the performance of a pneumoencephalography by means of a lumbar puncture (4,7), previous to the one done by Cunha. From 1932 onwards, Alejandro Figure 2.- First carotid arteriography by Schroeder, a neurosurgeon, percutaneous puncture in Uruguay, performed documented numerous cases of by Palma and Zerboni in 1936. Lateral view: hydatid cyst of the brain he had Puncture needle placed in the common operated on, after performing a carotid; the internal carotid and part of the ventriculography by means of a intracrania l carotid are also visualized. ventricular puncture followed by

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE

In 1940 an article called came into being because of the “Encephalography by the lumbar attraction the Latin American route”, signed by Alfonso Graña, medical community felt for Néstor was published in the annals of the Azambuja, whose career had been “C” Medical Clinic, directed at the acknowledged and appreciated by time by Dr.Julio García Otero. It is the Swedish School of the account of this procedure as neuroradiology (2,14). It was performed in 7 patients (11). In considered a school because these cases the attending scholars from 8 South American radiologist was surely Nicolás countries attended it in order to be Caubarrere, then radiologist at the C trained. They were either Medical Clinic. Later on, in 1944, he radiologists who wanted to learn would be appointed Associate neuroradiology or neurosurgeons Professor of Radiology (5). who wanted to learn the techniques In 1942, the review “Archivos because there were no specialized Uruguayos de Medicina, Cirugía y radiologists in their home countries. Especialidades” (Uruguayan Our description of the School will Archives of Medicine, and include its founder, Néstor Specialties) published “Suboccipital Azambuja, his Uruguayan pupils, encephalography, lessons gleaned Lía Zeiter and Andrés De Tenyi, and from 40 personal cases”,an article his Latin American pupils. from the clinic under the direction of Raúl Piaggio Blanco. The radiologist Néstor Azambuja (Fig 3) was Federico García Capurro. The advantages of the suboccipital route over the lumbar one were explained and a brief account of each of the 40 procedures was given (12). In 1947 Román Arana Iñiguez, soon to be the director of the Neurology Institute, returned from a 2-year stay in Chicago. After his return angiography was added to the diagnostic routine, not only by Arana but also by the few practicing neurosurgeons of the time. Radiologist Agustín Gorlero performed these studies with the neurosurgeons (13).

• Montevideo School of Neuroradiology It was created in the late sixties. Its seat was the Neurology Institute Figure 3.- Néstor Azambuja. from the Hospital de Clínicas (depending from the Facultad de Medicina, and as such part of the Universidad de la República) and

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Azambuja was born in the city of of this specialty. During this period Salto in 1920. He was admitted to he received scholars from Latin the Faculty of Medicine of America, the community so formed Montevideo in 1939. As a student was called School of Montevideo. he already focused on Radiology. Azambuja, who excelled as an He performed his first investigator, favored team work with neuroradiological studies with neurophysiologists, neurosurgeons, Eduardo Vigil Sóñora, a anesthesiologists and fellow neurosurgeon, and with Federico radiologists. His original García Capurro, the radiologist, at contributions focused mainly on the the Pasteur Hospital in 1943. Both following subjects: cerebral Eduardo Vigil and Raúl Piaggio herniation, central ventriculography, Blanco encouraged him to train in cerebrovascular accidents and neuroradiology. In 1944 he took an intracranial hypertension (15,16). internship at the Institute in Chile, then directed by Cerebral herniation. During his Alfonso Asenjo. In 1950 he stay at Lindgren's Department in submitted an individual paper on Stockholm, one of Azambuja's main contrast media for cerebral objectives was to study tentorial angiography to the Symposium herniations in the laboratory and in Neuroradiologicum. the X-ray room. He graduated in 1953 and was admitted on the same year as coworker to the Neurology Institute. The director was Alejandro Schroeder, who motivated him to qualify as a neuroradiologist in Sweden, at the Stockholm School, under the direction of Erik Lindgren, who was considered the father of neuroradiology. In 1957, Azambuja was admitted as foreign resident at the Serafinmerlasarettet in Stockholm. On his return, the new director of the Neurology Institute, Román Arana, asked him to take charge of all neuroradiological studies in that facility. In 1956 he Figure 4.-Tentorial herniations. A - Cover of became a member of the Hospital Acta Radiologica vol 46, includes the IV Británico (British Hospital) where the Symposium Neuroradiologicum. B - First page first Lysholm table in Montevideo of the article “Tentorial herniation, III. was installed. From that year on he Angiography”. devoted himself exclusively to neuroradiology. In 1958, the This study included anatomical, Neurology Institute was transferred pneumographic and angiographic to the Hospital de Clínicas and aspects. In the year 1955, at the VI Azambuja joined the Radiology Latin American Congress of Department at that hospital, thus Neurosurgery that took place in starting a teaching career at the Montevideo, Azambuja presented University that took him to the Chair his results for the first time. In the

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE

tomographic era (21). Lindgren cites this contribution in his article about History of neuroradiology (2) when describing this technique, and explains that Azambuja at the Neuroradiological Symposium of Rome presented it in 1961 but the summary was unfortunately not included in the Symposium publication. That is why it became known in Latin America where it had been presented in 1956 (21). This Figure 5- Tentorial herniations. A- Anatomic study provides a direct view of the section. Right -sided anterior herniation with third ventricle, the aqueduct of displacement of the posterior communicating Sylvius and the fourth ventricle, artery (17). B - (different case) Carotid avoids the superposition of the air- angiography. Posterior descending herniation, filled lateral ventricles, uses little air medial displacement of the distal portion of the and requires less head movements anterior cerebral artery (arrows) (19). than conventional ventriculography . (Fig. 6) same year, Erik Lindgren presented them at the IV Symposium Neuroradiologicum in London. On the following year the complete study, with its three parts (Anatomy, Pneumography, Angiography) was published in the Swedish review Acta radiologica (17,18,19). (Figs. 4 and 5) It made a great impact internationally and was cited in multiple publications. When he returned to Montevideo, Azambuja had acquired a deep knowledge of the anatomy of brain cisterns, so closely linked with herniations, and of herniation diagnosis with air- contrasted studies. Along with Lía Zeiter Carlevaro, he continued the anatomical and radiological study of retroalar herniations (20).

Central ventriculography. In 1956 Azambuja, Román Arana, María Figure 6.- Central ventriculography. Lateral Teresa Sande and Atilio García view: Catheter tip can be seen in the III Güelfi described central ventricle. Demonstration of III and IV ventriculography, an original ventricles and the aqueduct of Sylvius by air procedure that meant a great contrast are visualized(21). advance in the diagnosis of posterior fossa pathology in the pre-

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Stroke(cerebrovascular accident). with the operative specimens and During the sixties Azambuja was a with thrombi release; the prognostic team member of the Vascular and therapeutic importance of this Disorders Chapter at the Neurology observation led to the Institute. This working group took reconsideration of all the cases in part in an international study whose this joint study and to the final conclusions were published in modification of the protocols for the Journal of the American Medical surgical indication. (Fig. 7) This Association (22). finding was an important fact in the development of treatment of carotid disorders and as such, qualified for a later publication (23) Intracranial hypertension and cerebral shift. In collaboration with team members from the Experimental Neurology Laboratory directed by Elio García Austt, Azambuja studied the effects of intracranial hypertension (brain shifts) in animal experiments; the findings were in accordance with the scarce pathological evidence then available. At the time, investigation of the nervous system in this field was barely beginning and the first results were coming in (24,25). Azambuja held the Radiology Chair from 1975 until 1982. In 1985 was appointed Emeritus Professor by the Faculty Council at the UDELAR.

Figure 7.- Ulcerated atheroma plaques .A- Annular stenosis at the origin of internal carotid with poststenotic dilation. Atheromatous plaques in distal portions of internal and external carotids. The center plaque on the posterior wall has been replaced by an ulcerated crater. B- Ulcerated plaque of the posterior wall with stenosis approaching 50% (23).

This article relates how Azambuja and Zeiter, in 1965, presented the annual conference of this work group, their method for the radiological diagnosis of ulcerated atheromatous plaques at the carotid Figure 8.- Lía Zeiter Carlevaro. bifurcation and made the correlation

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE

Lia Zeiter (1927-1966) (Fig 8) Lía Zeiter Carlevaro showed her inclination for Radiology as an intern at the Neurology Institute, Azambuja therefore invited her to work with him at the Radiology Department at the Hospital Británico. After graduating in 1957, she was granted through competition the position of Instructor at the Radiology Department in the Hospital de Clínicas (Faculty of Medicine) and there she also worked in neuroradiology with Azambuja. She was his coworker and Azambuja always relied on her until her early death from lymphoma in 1966 at 39 years of age. She met Lindgren who thought she was surely going to make important contributions to neuroradiology. Her most important Figure 9.- Andrés De Tenyi. work in her joint investigations with Azambuja centered on vascular pathology of the brain. They were radiodiagnosis specialist and the first to describe ulcerations in devoted himself definitely to the atheromatous plaques of the neuroradiology. In 1972 he was one carotid, as explained in a later of the founding members of the publication (23). Latin American Society for Andrés De Tenyi (1937 – 2008) Neuroradiology. At University level, (Fig 9) Andrés De Tenyi was born in he completed his teaching career in Hungary in 1937 and emigrated to 1983 as Radiology Chair (16). As a Uruguay with his parents when he professor, De Tenyi excelled at was a child. He attended school, encouraging a friendly atmosphere high school and University in where physicians of other Uruguay. He graduated in 1965. As specialties, technicians, nursing a student he gravitated towards the personnel, helpers and foreign Neurology Institute, then directed by interns felt part of a whole (15).In Arana, and there he soon showed 1973 he performed his first free-flow an interest in neuroradiology, which embolization of an arteriovenous in the hands of Azambuja had malformation in Uruguay, marking developed a personality of its own. the starting point of endovascular Upon Lía Zeiter's early death, De interventionism. Bartolomé A. Grillo Tenyi took her place as assistant had introduced this technique to and coworker of Professor Uruguay a little earlier. De Tenyi Azambuja. Encouraged by his perfected his interventionist master he attended the Department methodology during successive of Professor Andreas Tänzer at the stays in France with renowned Eppendorf Hospital, as an intern, for specialists in this field like René a year. On his return to Uruguay, he Djindjan, Luc Picard and Jacques graduated in 1971 as a Moret. In later years he introduced

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0 both Computerized Tomography of Medicine in Pernambuco. He had (1979) and Magnetic Resonance studied neuroradiology with Dr (1993) to Uruguay in private Azambuja, from 1968 up to 1970 at practice. He died in the year 2008, his Department in the victim of a brain disorder. Neuroradiology Department of the Training of Latin American Hospital de Clínicas in Montevideo, neuroradiologists and completed his training with a The most lasting contribution of further stay in Professor Metzger's Azambuja to international radiology Department at the Pitié-Salpêtrière was to project the specialty in Latin Hospital in Paris. Dr. Holanda America and to train many of its first pioneered studies like gas neuroradiologists. From 1958 myelography and, at a later stage, onwards, the Neuroradiology Abrodil myelography (27).” Department at the Neurology Institute took in scholars from the From Dr Oscar Zamboni in following countries: Brazil, Argentina Argentina, Chile, Columbia, “Ramón Carrillo appointed my Venezuela, Paraguay, Peru and uncle, Dr Manuel Zamboni, who had Bolivia. the position of radiologist at the Some of the neuroradiologists Department, as trained by Azambuja went on to Head of the Radiology Department become pioneers of the specialty in at the new Neurosurgery Institute. their home countries, a fact that is Once installed in what was to be the reflected in the history of first Neuroradiology Department in neuroradiology in those countries. the country, Manuel Valls devoted The statements of some of them, himself with great zest to plain transcribed below, bear witness to radiographs of the skull, specially this. focusing on the temporal bone. In the late fifties I began to attend From Brazil the Department, where I took part in “...Dr Sérgio Raupp, born 1936, the activities as intern and also works as a neuroradiologist at the worked as assistant in Santa Casa Hospital of the neurosurgery, an experience that Pontifícia Universidade Católica in was most important for my future as Porto Alegre, in southernmost a neuroradiologist. Brazil, since 1960. In that year he Dr Azambuja, a neuroradiologist in presented his paper on the Neurosurgery Institute of the “Radiculography with water-soluble Faculty of Medicine in Montevideo, medium” as a doctoral thesis. He had trained in the early fifties at the completed his studies at Professor Karolinska Hospital in Stockholm Azambuja's Department in with Dr Lindgren, a specialist Montevideo and in Sweden, whence considered to be “the father of he brought the Seldinger technique modern neuroradiology”. On his and the use of catheters in return to Uruguay, Dr Azambuja angiography...” (26) began receiving foreign scholars, “...Neuroradiology was introduced in chiefly South Americans . I was the the northeastern region of Brazil by second of those scholars and Dr Glerystane R. B. de Holanda at attended the Institute during the the Pedro II Hospital, the former year 1961, on a grant from the Hospital de Clínicas of the Faculty “Costa Buero” Neurosurgery

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE

Institute on the initiative of Dr radiologists and neurosurgeons Lorenzo Amezua, an ardent from regions where no supporter of these diagnostic neuroradiologists were in practice. methods. Stage III: Imaging of brain On completing my scholarship with parenchyma Dr Azambuja in Montevideo, I rejoined the Radiology Department • Computed Tomography in 1962, contributing with the In the second stage (that of experience I had acquired in angiography and Uruguay and became the first full- pneumoencephalography) Néstor time specialist in this field (28). Azambuja had been the pioneer, but in the stage of brain parenchyma From Chile: imaging (CT, MR) it fell to Andrés “ In 1954 Dr Juan Ricardo Olivares De Tenyi to pioneer and inspire launched neurosurgery as a most of the development of the specialty at the Hospital Clínico of techniques. the Universidad Católica, He had The first EMI equipment arrived in trained with Dr Herbert Olivecrona Uruguay and was acquired by a (1891-1980) at the group of radiologists: Andrés De Serafimerlasarettet. Dr Mario Tenyi, Jorge Boschi and the Corrales (1933-1994), a graduate of brothers José Honorio and Félix the same university, was Leborgne. It was installed at the encouraged by Dr Olivares to enter Hospital Italiano (Italian Hospital). the neuroradiological On April 3, 1979, the first CT scan, and became the first Chilean corresponding to a patient with neuroradiologist. To to that end he frontal meningioma, was made with studied at the Hospital de Clínicas in the brand-new Uruguayan Montevideo with Dr Néstor equipment. (Fig. 10) Azambuja, one of the pioneers of the specialty in South America, who had created a school that made a huge contribution to the development of neuroradiology in the South Cone. Dr Azambuja was, in turn, a pupil of Dr Erik Lindgren from the aforementioned Serafimerlasarettet (29).”

After Azambuja finished his tenure as professor, Andrés De Tenyi succeeded him in the Chair . During his tenure, foreign scholars continued to come in order to train in neuroradiology at the Radiology Figure 10.- First computerized tomography Department at the Hospital de performed in Uruguay, April 2, 1979 at the Clínicas. Hospital Italiano. Axial slice with I/V contrast: In the period between 1958 and Frontal meningioma. 1992, a total of 46 scholars came in turn for their training. They were

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Two more equipments were to train abroad in these new installed in that year, both in private techniques. Among them were: at practice: Siemens equipment at the Hospital Italiano, Andrés De Sanatorio IMPASA by medical Tenyi and Jorge Boschi; at company and Elscint equipment at Sanatorio IMPASA, Juan Purriel, the Sanatorio Larghero by a Sasha Gordon Firing, Pedro Grille healthcare entrepreneur. Until 1987, and Daniel Pereyra (the latter as these three were the only spine specialist); and at Sanatorio operational equipments. Larghero, Gonzalo Pou, Néstor In that year 1987, during DeTenyi's Berois and Angélica Wozniak. professorial tenure, an Elscint equipment was installed at the • Magnetic Resonance Radiology Department of the The first equipment to be installed Hospital de Clínicas (Faculty of was a 1.0 Tesla Siemens Magnetom Medicine). This was an important Impact that operated at the Hospital event, since it allowed technicians Británico. (Fig. 11) and radiologists free access to the equipment, in order to learn and use this technique. CT was incorporated into the curricula of both the Medical Technology School and the Postgraduate School of the Faculty. Hospital technicians attended courses on the handling of this equipment and a handbook was drafted for the use of technicians, including protocols for different body regions. Many teachers were already experienced in CT, since they had been doing CT in private practice. Those teachers with no CT experience acquired it gradually after the installation of the tomograph at the university hospital. In this way, the Radiology Chair trained imaging professionals who were capable of performing and interpreting every technique and who met the increasing demand of CT specialists on account of the advent of more and more equipments in Montevideo and the provinces. For angiographic studies Figure 11.- First equipment of Magnetic the digital subtraction technique was Resonance to be installed in Uruguay, used. June 1993, Hospital Británico, Magnetom The first physicians to take in hand 1T. tomographic studies of the nervous system were radiologists, neurosurgeons and It was acquired on the initiative of neuropathologists. All of them had Dr. De Tenyi by a society consisting

[Dres. A. Wozniak, E. Wilson]

ORIGINAL ARTICLE of the Hospital Británico, CASMU (a professionals have been invited to medical insurance institution attend regional meetings as founded by the medical union) and a panelists and lecturers. group of physicians working at the Hospital Italiano (the technical staff PARTICIPATION IN MEDICAL of CT installed in 1979). This SOCIETIES equipment went operational on June Uruguayan neuroradiologists 1993. Before the end of the century have taken part in the organization other equipments were installed in of multiple academic activities along private practice and medical with other Uruguayan specialists insurance institutions: a 0.5 Tesla and the most distinguished GE equipment at Sanatorio neuroradiologists in the world. IMPASA, a 2 T Elscint equipment at Among these activities, in the Asociación Española on the same twentieth-century period we have year. Later on other equipments discussed, we want to emphasize were imported into the country. the entities below. Some of them, the one next to the Latin American Society for Hospital de Clínicas for instance, Neuroradiology founded in 1972 by operated only for a short time. Azambuja, Asenjo and other In this first stage the imaging distinguished Latin American physicians who were responsible for neuroradiologists. It met twice a neuroradiological diagnosis were: year, for the first time in Uruguay, Andrés De Tenyi and Jorge Boschi for the second time in Caracas. It at the Hospital Británico; Sasha was short-lived, given the Gordon Firing, Pedro Grille and tumultuous political life of the region Daniel Pereyra at IMPASA; and at the time (16). Pablo García Podestá, Claudia X Symposium Glausiuss and Alba Dietschi (the Neuroradiologicum. It took place in latter a spine specialist) at the 1974 in Punta del Este. It was Asociación Española. organized and presided by Finally, mention must be made of Azambuja, and attended by 400 the last-generation MR equipment at neuroradiologists from all around the Radiology Department of the the world (30). These symposia Hospital de Clínicas. Even if its late were the most important world advent (July 2010) leaves it outside events of the specialty. From the the time frame of this history, it was first one (Antwerp, 1939) on they most important academically. It provided a meeting place for the meant the introduction of the most important figures of technique in curricular teaching of neuroradiology. After a recess due Radiology, it provided training for to the Second World War, they have young radiologists, it made the taken place regularly every 3 years application of spectroscopy at first, then every 4 years. (Fig. techniques possible (until then, they 12) had not been employed), and it Latin American Hounsfield Club. made investigation projects This club was founded by Latin possible. The reports of these American neuroradiologists, several investigations were published locally of whom knew Hounsfield and regionally, and also presented personally, Azambuja among them. at national and foreign congresses. The promoter was Dr. Raúl Carrea, On their account, our young an Argentinean neurosurgeon, who

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ago and had been working there for a long time, and Enrique Palacios, Jesús Rodríguez Carbajal, Bernardo Boleaga and Marco Zenteno, mexicans who resided in their country This society meets in annual congresses in diverse seats in Spain, Portugal and Latin America. In the year 2000 it held the X Congress in Punta del Este. (Fig. 14) Three Uruguayan chairmen presided the Congress: Azambuja as Honour Chairman, Andrés De Tenyi as President and Fernando Viñuela as Chairman of the Scientific Committee. 300 Figure 12.-Some past presidents of Simposia neuroradiologists attended the Neuroradiologicae reunited in Washington in 1982. meeting from Latin America and Their presidential period appears between brackets. Europe. Scientific level was From left to right: Sitting: Giovanni Ruggiero (1961), excellent and the classic facilities of Georges Ziedses des Plantes (1949), Giovanni Di the Hotel San Rafael provided a Chiro (1982), James Bull (1955). Standing: Ingmar very suitable frame to this friendly Wickbom (1970), Sigurd Wende (1978), Juan reunion (32). Taveras (1964), Néstor Azambuja (1974).

installed the first CT equipment in Latin America, in the city of Buenos Aires. Reminiscing about Carrea, Horacio García says:”he created the Latin American Hounsfield Club so that the more dynamic and enterprising would be keen to join us in this new, unstoppable story that consolidated FLENI as a fundamental institution (31)”. The Club held several meetings, the first one in Buenos Aires in 1977, the second one in Punta del Este in 1981, the third one in Buenos Aires in 1983 and the fourth one in Punta del Este in 1986. (Fig. 13) Figure 13.- Meeting of the Hounsfield Club in Iberian and Latin American Punta del Este in 1981. From left to right: Néstor Neuroradiology Society (SILAN). Azambuja (president of the meeting), Pedro Grille It was created in 1989. Its promoters (neurosurgeon and neuroradiologist), Ernesto were Juan Taveras (Dominican Bastarrica, Eduardo Wilson, Jorge Méndez (all Republic) and Fernando Viñuela neurosurgeons, the latter a Chilean). (Uruguay), both physicians who had migrated to the United States years

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Fernando Viñuela graduated in Uruguay in 1970, trained as a radiologist and migrated to Canada in 1974 and then to the United States in 1986. He was a brilliant success as a specialist in at the UCLA (University of California at Los Angeles), where he holds the Chair of radiological Sciences and also directs the department of Interventional Neuroradiology. Figure 15.- Andrés De Tenyi, first president of SUNER, opening the Fundational Meeting, September 12, 1998.

Figure 14.- X Congress of SILAN , Neuroradiology for the III millennium, in Punta del Este, in Figure 16.- Foundational Meeting of SUNER the year 2000. Program cover. (Uruguayan Society of Neurorradiology), 1998. From left to right, last row: Pedro Leme (Argentina), Pedro Grille, Jordi Ruscalleda (Spain), Pablo García Podestá, Jorge Boschi Pau, Fernando Slovinski Uruguayan Society of (Brazil); middle row: Sérgio Raupp (Brazil), Lilián Neuroradiology, SUNER. It was Acosta, Sasha Gordon Firing, Eduardo Raupp founded in an international meeting (Brazil); first row: Angélica Wozniak, Oscar Zamboni with guests from the region, the (Argentina), Andrés De Tenyi, Teresa Lin, Thomas United States and Europe, that took Naidich (USA), Nestor Azambuja, Marco H. Modesto place in Montevideo on September (Brazil). 12, 1998. Its first president was Andrés De Tenyi, who held that The second meeting was held position for two years. (Figs. 15 and simultaneously with the III Congress 16). of the Neurosurgery Society of the

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South Cone. A very distinguished perfected, the number of specialists US neuroradiologist, Thomas has greatly increased and so has Naidich, was a special guest. SUNER has around 20 members the number of diagnostic and and holds joint meetings with the therapeutic techniques. It will fall to Uruguayan Neurosurgery Society and the Society of Radiology and others to continue this narration. Imaging of Uruguay (SRIU). ACKNOWLEDGEMENTS. We FINAL WORD. Here ends our report thank all who have contributed on the history of Uruguayan information and photographs to this neuroradiology in the twentieth history. Even at the risk of omitting century. What comes later is the names, special thanks must go to Dr present time. The first years of the Néstor Azambuja, Mrs Ilse Ruiz ongoing century have brought much Tenyi and Dr Pablo Carlevaro. progress, equipments have been

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[Dres. A. Wozniak, E. Wilson]