Country of the month: Austria

by Eugen Trinka

As Vienna, Austria will host the 7th Annual Congress of the European Academy of Neurology, below is a previously published Country of the Month article from Austria.

Read more about the EAN Congress 2021

The best starting point to characterize Austria is with history. Our small country is deeply rooted in the history of the Habsburg Empire, but at the same time Austria has been a spearhead in modernism of the 20^th century, and it is one of the most developed social welfare states in today’s world.

Austria has currently only 8 million inhabitants, and covers close to 84.000 km² of mostly alpine regions. However, at the beginning of the last century, Austrian population counted more than 50 million inhabitants, 11 nations, and 676.000 km² (i.e., the second largest country in Europe).

The remarkable multicultural character of the Habsburg empire under one administrative structure in Vienna was the base for an extremely fruitful period where arts, science, literature, music, and philosophy flourished and developed many ideas which formed the 20^th and 21^st century as we see it today (Figure 1).

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Figure 2

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Figure 5

Outstanding personalities came together from the capital, Vienna, but also other big cities of the Empire, such as Prague or Budapest. Some examples are: Gustav Klimt (Figure 2 and 3), Egon Schiele, and Oskar Kokoschka in Arts; Arthur Schnitzler, and Hugo von Hofmannsthal (Figure 4) in Literature; Gustav Mahler, Webern, and Schönberg in Music; Otto Wagner, Olbrich,

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and Adolf Loos in Architecture; Menger, Böhm von Bawerk, and Ludwig von Mises in Economy; Hoffmann, and Koloman Moser in Design; Kris, Riegel, and Gombrich in History of Arts. Philosophy found an extremely fruitful ground in Vienna with Schlick, Carnap, Feigl Frank, Kurt Gödel (Figure 5), Ludwig Wittgenstein (Figure 6), and Karl Popper being the intellectual landmarks in Science, logic positivism, mathematics, and the social sciences of the free world. Unfortunately, it all came to a sudden end with the rise of the Nazi Regime in Austria, and the “Anschluss” to Germany in 1938, when almost all members of the most productive Jewish community had to flee or were murdered. Austria and Europe never recovered completely from this enormous cultural loss.

Today Austria found its role as a diplomatic mediator between East and West, and different cultural systems within Europe. The Austrians are generally friendly and welcome the visitors with open arms. They are cultivated and have a sense of traditions. Austrians have an ironic humor, and they can laugh about themselves. When others say, “the situation is serious but not hopeless”, the Austrian would say, “the situation is hopeless, but not serious”! This type of humor takes out some gravity when we Austrian solve problems, and most of the time whenever we work together we come to productive conclusions and good compromises.

In the 18^th and 19^th century, a modern and well-structured academic medical system was developed. The Viennese Medical School (Figure 7) rose to world-wide fame, and brought extraordinary contributions to medicine, surgery, and last but not least to Neurology and Neurosciences. In my personal opinion, the critical density of outstanding personalities led to the following intellectual heights (Figure 8): Carl von Rokitansky (1804-1878), Ludwig Türk (1810-1868), Theodor Meynert (1833-1892), Sigmund Freud (1856-1939), and Richard von Krafft-Ebing (1840-1902), who interacted closely at times in friendly discussions and also engaged in fierce disputes. They met in public coffee houses or in Salons, which were typical of that time in the major cities of Europe. Berta von Zuckerkandl was the dominant figure, regarded as the most influential “Saloniere” at that time – as a Jewish citizen she also was forced to leave the country in 1938, and died in Paris.

Figure 8

Neurology, as a separate specialty, started in Austria in the middle of the 19^th century. The first department of Neurology was founded in 1846, with Ludwig Türk (1810-1868) being its founding director. He made several contributions to the anatomical understanding of fibrous networks of the Central Nervous System. His younger contemporary Theodor Meynert (1833-1892) became Lecturer in Neuroanatomy at the University of Vienna at the age of 32 years, and later Director of the Department of Psychiatry at the Vienna Allgemeines Krankenhaus in 1876. He was most active and is still remembered for his identification and description of the basal Forebrain Nucleus which has become recognized as a major source of cortical cholinergic innervation. Meynert was also politically very influential, and one of the strongest opponent to Sigmund Freud and his revolutionary new theories. Another pioneering personality was Heinrich Obersteiner (1847-1922), who founded the first Institute what we would now be called Neuroscience Institute (Klinisches Institut für Neurologie). Obersteiner was a founding member of the International League against Epilepsy, and served as member of the Journal “Epilepsia” from 1909-1915. In 1873, he published the first German publication on Status Epilepticus. This Institute became the prototype of an interdisciplinary Neuroscience Centre, which later developed in many Universities throughout the world in an attempt to provide the infrastructure for translational multidisciplinary brain research. Otto Marburg, who was Obersteiner’s successor at the “Klinisches Institut für Neurologie”, described what he called “acute multiple sclerosis”. The Neuropathologists Ernst Sträussler and Josef Gerstman described what we now identify as a hereditary prion disease. Constantin von Economo delineated Encephalitis Lethargica in the aftermath of the First World War, and the influenza pandemic. His work formed the basis for the identification of the ascending reticular system, and the regulation of sleep/wake-circle. Julius Wagner von Jauregg, who chaired the departments for Neuropsychiatry in Graz and Vienna, was awarded for the Nobel-Prize for Medicine in 1927 for his introduction of the Malaria-Therapy for progressive paralysis in chronic Neurosyphilis. Another Nobel Laureate was Robert Bárány (1876-1936) who was native Austrian and trained in Vienna. He received the Nobel Prize for his work on Physiology and Pathology of the Vestibular System in 1914. In 1960, Oleh Hornykiewicz described the dopamine depletion in the human’s striatum in patients with Parkinson’s disease together with his colleague H. Ehringer. And only one year, later together with Walther Birkmayer (1910-1996) first reported the dramatic effects of levodopa in revising akinetic symptoms.

Most of the aforementioned achievements in Clinical Neurology and Neuroscience were made when Neurology and Psychiatry were regarded as one medical subspecialty. Hans Ganner (1905-1995) chaired the Innsbruck “Nervenklinik” (University Department for Neurology and Psychiatry), and called Psychiatry the “uneven sister” of Neurology in 1968. While in other European countries such as Germany, France, and especially the United Kingdom, Neurology evolved from Internal Medicine and not from Psychiatry, Austrian Neurology was still represented by one society for Neurology and Psychiatry with one common education, being all neurologists trained also in Psychiatry. When the new medical education system was introduced in the ‘90s, the former society for Psychiatry and Neurology split, and the Austrian society for Neurology was formed. The first standalone congress for Neurology was held in 2000, and it was an enormous success with annual iterations since then. Nowadays, the Austrian society for Neurology plays an active role in medical education. It is also the consulting body for the Austrian Chamber of Physicians and the Healthcare Ministry. The Austrian Society for Neurology sees itself also as a scientific voice for the development of Neuroscience, and the platform for international exchange within the European Academy of Neurology, the World Federation of Neurology, and Leading Medical Organizations such as the International League against Epilepsy, Movement Disorder Society and World Stroke Organization.

There are four public and one private Medical Universities in Austria, offering a curriculum for medical training (Wien, Innsbruck, Graz, Linz and Salzburg), whit a total of almost 2,000 students being trained. While the entry to study is, except from the private Paracelsus Medical University in Salzburg, still free for all, there is a strict selection process, consisting of written information assuring the high quality of the medical students. 75% of the places are reserved for Austrian students, and 25% for students from the European Union, mostly from Germany. About two thirds of all students remain in the medical field and work in Austria as doctors. Given the epidemiological change with a growing number of elderly in our population, and the expected shortness of doctors due to retirement, we have to increase not only the number of the students, but also the attractiveness of the hospital and public practices in medicine. As neurological diseases and problems are common in general practice, it is of highest importance that all medical students receive a high quality neurological education during their studies, but also in their subspecialty training. Like in most European countries, the curriculum for becoming a neurologist follows a formal pattern, given by the Austrian Chamber of Physicians and the Austrian Ministry of Health. Currently, it comprises of six years of education, including three years with structured clinical rotation within Neurology, and a further 27-month specialization in Neurorehabilitation, Clinical Neurophysiology, Neurogeriatrics, Neurooncology, Neurological Emergency, Intensive Care Neurology, and Comprehensive Stroke-Management. Each of these modules consists of nine months of structured medical education in tertiary centers. Every trainee must choose three of them according to his or her own preference. After finalization of the training, further specialization is possible in Psychosomatic Medicine, as well as in Sleep Medicine. A curriculum for specialization in Neurointensive Care is currently under discussion, in the same way as a specialization for Neurointerventional Therapies, in collaboration with the Austrian Chamber of Physicians, the Austrian Society for Neurology, responsible for Board Examinations, which is the final step in the process of subspecialty certification. Approximately 40-50 trainees are newly accredited as subspecialists in Neurology. The Austrian Society of Neurology also stipulates that participation in the European Board Examinations is mandatory. The future employment perspectives for the trainees are good, as we still have a shortage of qualified neurologists in the rural areas, and due to the retirement of many colleagues in the next years, we will have a high demand of young neurologist in the future.

Austria has a good number of trained neurologists and neurological departments. The Austrian Society for Neurology has now 1.406 members, with more than 800 board certified neurologist, corresponding to roughly 1 neurologist in 10,000 inhabitants. Compared to other European countries, the per capita ratio seems high, but one has to take into consideration that Austrian neurologists usually take care also of lower back pain syndromes and stroke-rehabilitation.
Austria has a total of 63 neurological departments. The structural quality criteria demand that there should be at least 30 beds for inpatients available per department. The largest departments have more than 100 inpatient beds. The stroke unit is intrinsically related to neurology departments. Two types of stroke units have been established. The first is a basic stroke unit, where all treatments are available, except the neuro-interventional ones. They should comprise at least of 4-6 beds. In the densely populated areas, comprehensive or advanced stroke centers have been established, which provide a 24/7 thrombectomy service, and also neuro-intensive or general intensive care unit, as well as a Department for Neurosurgery

Figure 9

with a 24/7 service. In Austria, there are now 37 Stroke Units, and 8 Neuro-ICUs fully established. The healthcare plan also provides a minimum number of beds for Neuro-Rehabilitation after an acute brain insult. These beds are also attached to the neurology department. Long-term rehabilitation or rehabilitation for chronic diseases mostly takes place in stand-alone rehabilitation-centers (phase C + D).
The Austrian Ministry of Health, together with the Austrian Society for Neurology, has implemented a plan implementing that any stroke patient in Austria should have access to a specialized stroke care within 16 minutes, despite the mountainous region. This is already the case for about 90% of the country. For 80% of Austria a stroke unit can be reached within in 45 minutes (Figure 10).

Austrian neurologists have been very active in International Societies, and some have become leading figures in their field (Figure 9). Prof. Franz Fazekas is Professor of Neurology at the University Graz in Austria, and has been elected President of the European Academy of Neurology in 2018. Prof. Wolfgang Griesold is currently the Secretary Treasurer General of the World Federation of Neurology.  Prof. Michael Brainin is the Head of the Department for Clinical Neuroscience and Prevention Medicine at the Donau University Krems. He was President of the European Stroke Organization in 2012-2014, Treasurer of the World Stroke Organization in 2008-2014, and the President of the World Stroke Organization since 2018. Prof. Werner Poewe, currently the Chair of the Department of Neurology of the Medical University Innsbruck, was President of the International Movement Disorder Society in 2000 -2002. Prof. Eugen Trinka is currently the Chair of the Department of Neurology at Paracelsus Medical University in Salzburg, and served as a Treasurer of the International League Against Epilepsy Europe in 2009-2017, and was appointed as Chair of ILAE Europe in 2017.

Professor Eugen Trinka is member of the Management Group of the EAN Scientific Panel on Epilepsy and President of the Austrian Society of Neurology.

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