A life in epilepsy

The symposium Epilepsy at the Cutting Edge, organized by Jean Gotman and François Dubeau, was for us an extraordinary and unforgettable experience. Seeing so many of our former students and fellows, some of whom came from very far away, and hearing the reminiscences of their experiences at the Montreal Neurological Hospital and Institute (MNH/MNI), followed by accounts of their clinical and scientific achievements, made us very proud. Many of them have taken the original work that they did here and expanded it to higher levels. The only regret that we have is that time did not permit us to speak to all our friends individually and to be brought up to date on their lives and families. We are honored that so many of the participants have agreed to contribute to this supplement, and we will cherish it as a memento of the symposium. The three main themes of the symposium: malformations of cortical development, genetics of idiopathic epilepsies, and investigational and surgical aspects of the epilepsies have been beautifully illustrated in a number of original and imaginative papers. We regret that there was no time at the symposium for two other topics dear to our hearts, on which we have also worked for many years: outcomes of pregnancy in epileptic women and teratogenic effects of anticonvulsant medications; as well as recognition of various neurogenetic syndromes associated with epilepsy, such as the action myoclonus-renal failure syndrome. Between the two of us, we have worked at the Montreal Neurological Hospital and Institute for a total of 95 years, if we include Fred’s residency training and Eva’s PhD thesis work on genetics of focal epilepsies, as well as her EEG training under Peter Gloor. We are both greatly indebted to our mentors: Francis McNaughton, Preston Robb, Herbert Jasper, Peter Gloor, and Julius and Katherine Metrakos, who stimulated our interest in epilepsy, EEG, and genetics. We were very fortunate to have those giants in the field as our teachers and role models, and later as friends. At the beginning of Fred’s training in epilepsy, it was not at all clear that there was scope for a career in this field at the MNI, since everybody including the elevator men and the cleaners seemed to be well versed in the investigation and treatment of people with epilepsy. As the generations turned over, the wisdom of the decision to pursue work in this field became increasingly apparent and it has been a very fulfilling and, we hope, constructive choice. Following her training in medical genetics, Eva founded the first neurogenetics department in Canada at the MNH/MNI in 1973, while continuing her research in genetics of the epilepsies and other hereditary neurologic disorders, as well as her work in EEG and electrocorticography. We have witnessed tremendous changes in the expectations of patients and family members of people with epilepsy, and the advances in medical and surgical treatment have been very gratifying. The days when treatment of epilepsy was initiated without preliminary investigation are fortunately over, never to return. Sophistication on the part of patients and families requires clarification of the problem and educated prognosis, which is now an essential part of the management and treatment of people with seizures. We well remember the days when patients would reappear with recurrent seizures and a zero Dilantin level. This state of affairs is by now quite exceptional, again because of increased understanding and sophistication on the part of patients and improved interpretation of the treatment plan. In recent years, an increasing number of new antiepileptic molecules with fewer side effects and perhaps fewer risks have been developed, and yet much remains to be done. The pharmacologic industry has veered toward a search for “billion dollar molecules” and away from investing in the study of antiepileptic agents, which cannot be expected to produce incomes of that magnitude. There are fortunately some exceptions including particularly UCB, the patron of this symposium. The treatment gap continues to be a major problem. We have been forced to recognize that for economic and financial reasons the use of phenobarbital for control of epilepsy must be encouraged in some parts of the world, whereas in the more affluent countries its utilization has been increasingly discouraged because of side effects. The work of the International League Against Epilepsy (ILAE) has flourished, and branches of the League are now active in more than 100 countries. Regretfully, there are still parts of the world, notably in Africa, where progress has been slow, education laborious, and investigation and treatment facilities inadequate. Fred’s years of service to the ILAE have been a source of great satisfaction, and the torch has now been handed to a younger generation, which we are sure will continue the work with enthusiasm. Eva was one of the founders of the Commission on Genetics, Epilepsy and Pregnancy of the ILAE, and also served on the Task Force on Classification. She continues to head the Neurogenetics Research Group of the World Federation of Neurology, and has organized many meetings and courses on neurogenetics both at the MNI and worldwide. The recognition of genetically determined forms of epilepsy, and in particular the advances in molecular studies of the epilepsies, have opened a new horizon, and we are only at the beginning of this revolutionary approach. It has been very gratifying that genes for several syndromes, which we first described in the 1970s and 1980s, have been identified in the last decade, allowing carrier screening, presymptomatic and prenatal diagnosis, improved genetic counseling, and, it is hoped, specific treatment in the future. We have witnessed great strides in the availability of surgical treatment of epilepsy in many parts of the world, following the fading of prejudice against such an approach. Recognition of ideal surgical candidates not only in technologically well supplied areas, but even in poorer countries, has brought the benefits of surgical treatment to increasing numbers of centers worldwide. At the same time, ideal surgical candidates are increasingly rare in areas where surgical treatment has been available for some decades, and patients with intractable epilepsy present more and more complicated diagnostic and management problems. One cannot overestimate the role modern imaging has played in clarifying the causes of epilepsy. The enormous proliferation of publications and information regarding cortical dysplasia is a striking example of this. In Canada, perhaps because of the presence and spirit of Wilder Penfield and his school, there has been a proliferation of centers where surgical treatment of epilepsy is practiced, with no less than 14 units in a population of 30 million. Epileptology has emerged as a neurologic subspecialty with a reduction of the burden of intractability, improved understanding, and a reduction in prejudice. We have been fortunate to be a part of the epilepsy movement during the last half century, and we are proud of the progress and advances achieved by our students and disciples with whom we have formed indelible bonds of friendship and continued collaboration. Despite the increasing sophistication and availability of diagnostic and treatment methods, much remains to be done. Ignorance, and in particular prejudice, continue to be important problems, despite the efforts of the lay societies and in particular the International Bureau for Epilepsy. The tendency for rivalries and competition among lay societies remains a problem, quite prevalent in many parts of the world. Improved management of epilepsy in pregnancy and clarification of the teratogenic effects of some of the antiepileptic agents have enabled more women to become successful mothers and to lead fulfilling lives. At the Montreal Neurological Hospital and Institute, the work in the different aspects of epilepsy investigation and treatment is continuing to flourish and the future is secure and rests in good hands and minds, best exemplified by the organizers of this symposium. On a more personal level, in addition to our neurologic children and grandchildren who made this meeting a success, we are pleased that our biologic children and their families could also participate in the symposium (Fig. 1). We are justifiably proud of the achievements of our children: our daughter Lisa, an expert in transcultural psychiatry; Anne, a public health specialist; our son Mark, a neuroscientist; and their equally talented spouses. It has been a good life, full of satisfaction and progress, and it has been a wonderful opportunity to reflect upon this while we are present and still able to continue working. Fred and Eva Andermann with children Anne, Mark, and Lisa, and granddaughter Hannah, in front of the MNI mural by Mary Filer. With respect to this article, the authors declare no conflicts of interest.

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