INDIAN SOCIETY OF NEURORADIOLOGY
                            Regd. No:781/99-2000

Ramamurthi's Contribution to NeuroRadiology

The doyen of neuroradiology in India, B.Ramamurthi, narrowly missed the opportunity of performing an open carotid angiogram in 1946. In the summer of 1949, he introduced the technique in Newcastle-upon-Type, England, having learnt it from Rowbotham at Manchester. When he returned, to start neurosurgery in Madras, there were formidable challenges and limitations. He had to work with the all-powerful general surgeons at the medical college and hospital. They decreed that he could perform his tests and operations only after they had finished their work for the day. The craniograph sanctioned by the government could not be put to use by him for 2 years, as there was no x-ray tube on the machine ! The bureaucrat placing the order had overlooked the need for this component. 

The timely arrival of Mahadevan Pillai as radiologist to the Barnard Radiology Institute at the hospital helped Ramamurthi in investigating his patients radiologically. The outbreak of the Second World War had compelled pillai to return to India after qualifying in radiology in England. He contributed greatly to the recognition and advancement of neuroradiology as a discipline. His profound knowledge of clinical medicine and excellent technical skills in radiology made his colleagues seek his advice on radiological methods and interpretation. Ramamurthi found him an enthusiastic colleague. At that time plain x-ray formed the mainstay in the diagnosis of space occupying lesions. Sellar changes, bone erosion, hyperostosis and pineal shifts were looked for eagerly. In 1952, Pillai and Ramamurthi embarked on percutaneous direct carotid angiography as a routine diagnostic procedure. Ramamurthi recalls with nostalgia how he used to wheel the patients with stereotactic frame fixed on their heads from his ward to the radiology department to the amazement of onlookers in the long corridors. Gradually pneumoencephalography, ventriculography and myelography were introduced. His association with such giants among European neuroradiologists as JWD Bull, Pendergrass, Lindgren and Seldinger helped Mahadevan pillai pioneer several techniques in our country. Apart from being an astute radiologist he was a great innovator and with the help of a local technician he designed a manual changer(to hold cassettes in series with springs for serial angiography) costing just Rs.160. In a similar manner connecting tubings, needle positioners etc. were locally fabricated and used for angiography. The obtained the Seldinger percutaneous puncture needle and long rolls of catheter tubing from Lysholms radiology department in Sweden and carried out the first transfemoral carotid angiography at Madras. He enjoyed teaching the technique of catheterization to his students. Like many other clinicians interested in neuroradiology, Krishnamoorthy Srinivas, whilst in training in neurology, worked with Sydney P.Traub and was soon performing PEG, Angiography and Myelography independently. In London he worked with James Ambrose who helped him sharpen his angiographic techniques. On his return to Madras, he put these to good use. 

During this period, at Vellore the aggressive zeal of Jacob Chandy to establish neurosurgery and neuroradiology was complemented by the enthusiasm of eminent radiologists like Seudder, Patterson and Johnson. In Bombay, R.G.Ginde, Homi Dastur and J.N.Sidhava developed neuroradiology from 1955 onwards. Schoenander skull tables were installed at the Sir Jamesetjee Jejeebhoy (JJH) and King Edward Memorial Hospitals (KEMH) and cerebral angiography was started on a regular basis by Sidhava (JJH) and Homi Dastur (KEM) using serial film changers. P.E.Billimoria started catheter angiography at the JJH in 1960 and performed vertebral angiography through this route. K.V.Chaubal, retired professor of orthopaedic surgery, Topiwala National Medical College, recalls Billimorias unequivocal demonstration in 1963 of hemistenosis of the lumbar canal in a patient complaining of unilateral sciatica. 

In 1958 Ginde recognized the skills of D.S.Dadhich in radiology and arranged his visit to the Montreal Nerological Institute for training under Donal McRae. At the instance of Prakash Tandon, Dadhich sailed to Oslo to work with Frimandahl and Amundson at the Ulleval Hospital. In 1961, Dadhich went to Lindgren at Stockholm and later worked with Wickvlom at Gothenberg before returning to Bombay by the end of the year. By this time the Bombay Hospital was equipped with a Schonander skull table, tilting table for myelography and a serial changer. Dadhich quickly put the equipment to use and performed the first transfemoral vertebral angiogram at the Bombay Hospital. 

Ginde (JJH) and Homi Dastur (KEMH) occluded carotid-cavernous fistulae by floating muscle grafts through external carotid arteriotomies perhaps the first interventional neuroradiological procedures to be performed in this country. Homi Dastur (KEMH) studied hydromelia by air myelography from 1969 onwards and was able to demonstrate the collapse of the cervical spinal cord on auto tomography. 

In 1960 Sidhva (along with Erik Lindgren, Ziddes des plantes, Fischgold and others) was appointed on the Problem Commission on Neuroradiology of the World Federation of Neurology. Sidhava was the only Asian member. For his pioneering work on positive contrast cisternography, Sidhava was awarded the Sarat Kumar Gold Medal of the Indian Radiological Association in 1970. 

In 1959, the techniques of fractional pneumoencephalography, myodil verntriculography and carotid angiography were simultaneously introduced at the Tirath Ram Shah Hospital, Delhi and at the K.G.Medical College at Lucknow. These conventional diagnostic procedures were established at the All India Institute of Medical Sciences (AIIMS), New Delhi by 1963. 

Around 1960, Lt. General Prataprao specialized in neuroradiology at Guys Hospital, London and he became the architect of neuroradiology in the Armed Forces Medical Services. His interest in neuroradiological evaluation of epilepsy and stroke with detailed clinical correlation won him the Sir J.C.Bose Oration and a Gold Medal. 

The demands of neurosurgeons for precise diagnostic support helped the development of neuroradiology as a discipline. Ganguly, Varadarajan, Shyam Sharma, Goulatia and later Arya, Meera and Vasundhara are prominent among those devoting themselves fully to this specialty. Varadarajan was a close associate of Ramamurthi and contributed to several techniques in neuroradiology. With undiminished energy he continues to publish his clinical experiences. The rich contributions of Shyam Sharma on craniovertebral junction anomalies received wide attention in our country and Goultias work on the empty sella and disappearing lesions on computerized tomography added greatly to clinical management. 

Gajaraj, the architect of modern neuroradiology at Madras had his training at the Royal Victoria Infirmary and Newcastle General Hospital. Bruce, Klaus Bron and John Feist guided him. In 1970, he was appointed Director of Barnard Institute of Radiology. He created a separate section of neuroradiology, starting with the appointment of a lecturer and then upgrading the post to that of a reader and then professor. He set up nuclear imaging with Rajagopalans help and studied CSF circulation using Ytterbium DTPA. 

Sneha Bhargava opened new vistas for neurodiagnosis in India with the installation of the first computerized tomographic scanner at the AIIMS in 1978. Pneumoencephalography was soon rendered obsolete. The studies at AIIMS threw new light on tuberculosis of the central nervous system and cysticercosis. With the availability of digital subtraction angiography unit, another whole body C.T. scanner and transcranial sonography the AIIMS has achieved the status of the center of excellence in neuroradiology. 

Mahadevan Pillai laid the foundation of a fully equipped neuroradiology department at the start of the national Institute of Mental Health and Neurosciences (NIMHAS) at Bangalore. After a brief stint at Zambia, he returned to Trivandrum and organized the department of radiology at Sree Chitra Tirunal Institute in 1977 and shaped the careers of many youngsters neuroradiology. His intense interest in imaging and knowledge in clinical neurology was a tremendous help to the young clinicians and the radiologists alike. As an administrator he gave full liberty to the youngsters to attempt and establish special procedures such as magnification angiography, stereoscopic angiography, air myelography and spinal angiography. Unforgettable is his borrowings a new connecting tube from me for angiography at the age of 73, when he was a consultant to a nursing home. 

By 1977, magnification and subtraction angiography became the order of the day at Sree Chitra Tirunal Institute, Trivandrum. Demonstration of collapse of syringomyelic cord in 1978 was an exciting experience. At the time when myodil ventriculography was generally in vogue, water-soluble contrast medium was used here in more than 800 patients. With the availability of image intensifier, arterial catheters, and the injection pump, percutaneous transfemoral pan cerebral angiography became a routine. 

Co-operation and mutual understanding between the surgical team and neuroradiologists gave birth to the frontier area of neurointervention. Free flow muscle embolization was introduced for the treatment of large and inaccessible arteriovenous malformations. After preliminary animal experiments with the use of liquid polymer embolic agents, first hand experience was gained in super selective catheterization and embolization of cerebral and spinal arteriovenous malformations with isobutyl 2-cyanoacrylate. Techniques using coaxial micro catheters for detaching balloons and coils in carotid-cavernous fistulae and aneurysms of the carotid were perfected. Therapeutic embolisation is currently being carried out at the Sree Chitra Tirunal Institute, Trivandrum by the author; King Edward Memorial Hospital, Bombay by Anil P.Karapurkar and Ravi Ramakantan; National Institute of Mental Health and Neurological Sciences, New Delhi by Goulatia and Mirsa. Arteriovenous malformations, arteriovenous fistulae, selected aneurysms and vascular tumours in the cranium and spine are being treated thus at each of these centers.