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Arquivos Brasileiros de
Órgão oficial: sociedade Brasileira de Neurocirurgia e sociedades de Neurocirurgia de líNgua portuguesa
NeurocirurgiA
ISSN 0103-5355
Volume 31 | Número 2 | 2012
brazilian archives 
of neurosurgery
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Arquivos Brasileiros de
Órgão oficial: sociedade Brasileira de Neurocirurgia e sociedades de Neurocirurgia de líNgua portuguesa
NeurocirurgiA
ISSN 0103-5355
brazilian archives 
of neurosurgery
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sociedade Brasileira de Neurocirurgia
iNstruções para os autores
Arquivos Brasileiros de Neurocirurgia, publicação científica 
oficial da Sociedade Brasileira de Neurocirurgia e das Sociedades 
de Neurocirurgia de Língua Portuguesa, destina-se a publicar 
trabalhos científicos na área de neurocirurgia e ciências afins, inéditos 
e exclusivos. Serão publicados trabalhos redigidos em português, com 
resumo em inglês, ou redigidos em inglês, com resumo em português.
Os artigos submetidos serão classificados em uma das categorias 
abaixo:
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• Artigos diversos: são incluídos nesta categoria assuntos 
relacionados à história da neurocirurgia, ao exercício 
profissional, à ética médica e outros julgados pertinentes aos 
objetivos da revista.
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resumida, ética e educativa, sobre matérias publicadas nesta 
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seis palavras-chave, com base no DeCS (Descritores em 
Ciências da Saúde), publicado pela Bireme e disponível 
em http://decs.bvs.br.
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resumo para o inglês; indicar key-words compatíveis com as 
palavras-chave, também disponíveis no endereço eletrônico 
anteriormente mencionado.
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5. Referências: numerar as referências de forma consecutiva 
de acordo com a ordem em que forem mencionadas pela 
primeira vez no texto, utilizando-se números arábicos 
sobrescritos. Utilizar o padrão de Vancouver; listar todos 
os nomes até seis autores, utilizando “et al.” após o sexto; 
as referências relacionadas devem, obrigatoriamente, ter 
os respectivos números de chamada indicados de forma 
sobrescrita, em local apropriado do texto principal; no 
texto, quando houver citação de nomes de autores, utilizar 
“et al.” para mais de dois autores; dados não publicados 
ou comunicações pessoais devem ser citados, como tal, 
entre parênteses, no texto e não devem ser relacionados 
nas referências; utilizar abreviatura adotada pelo Index 
Medicus para os nomes das revistas; siga os exemplos de 
formatação das referências (observar, em cada exemplo, a 
pontuação, a sequência dos dados, o uso de maiúsculas e o 
espaçamento):
Artigo de revista
Agner C, Misra M, Dujovny M, Kherli P, Alp MS, Ausman JI. 
Experiência clínica com oximetria cerebral transcraniana. Arq 
Bras Neurocir. 1997;16(1):77-85.
Capítulo de livro
Peerless SJ, Hernesniemi JA, Drake CG. Surgical management 
of terminal basilar and posterior cerebral artery aneurysms. In: 
Schmideck HH, Sweet WH, editors. Operative neurosurgical 
techniques. 3rd ed. Philadelphia: WB Saunders; 1995. p. 1071-86.
Livro considerado como todo (quando não há colaboradores 
de capítulos)
Melzack R. The puzzle of pain. New York: Basic Books Inc 
Publishers; 1973.
Tese e dissertação
Pimenta CAM. Aspectos culturais, afetivos e terapêuticos 
relacionados à dor no câncer. [tese]. São Paulo: Escola de 
Enfermagem da Universidade de São Paulo; 1995.
Anais e outras publicações de congressos
Corrêa CF. Tratamento da dor oncológica. In: Corrêa CF, 
Pimenta CAM, Shibata MK, editores. Arquivos do 7º Congresso 
Brasileiro e Encontro Internacional sobre Dor; 2005 outubro 19-
22; São Paulo, Brasil. São Paulo: Segmento Farma. p. 110-20.
Artigo disponível em formato eletrônico
International Committee of Medial Journal Editors. Uniform 
requirements for manuscripts submitted to biomedical journals. 
Writing and editing for biomedical publication. Updated October 
2007. Disponível em: http://www.icmje.org. Acessado em: 2008 
(Jun 12).
6. Endereço para correspondência: colocar, após a última 
referência, nome e endereço completos do autor que deverá 
receber as correspondências enviadas pelos leitores.
7. Tabelas e quadros: devem estar numerados em algarismos 
arábicos na sequência de aparecimento no texto; devem estar 
editados em espaço duplo, utilizando folhas separadas para 
cada tabela ou quadro; o título deve ser colocado centrado 
e acima; notas explicativas e legendas das abreviaturas 
utilizadas devem ser colocadas abaixo; apresentar apenas 
tabelas e quadros essenciais; tabelas e quadros editados em 
programas de computador deverão ser incluídos no disquete, 
em arquivo independente do texto, indicando o nome e a 
versão do programa utilizado; caso contrário, deverão ser 
apresentados impressos em papel branco, utilizando tinta 
preta e com qualidade gráfica adequada.
8. Figuras: elaboradas no formato TIF; a resolução mínima 
aceitável é de 300 dpi (largura de 7,5 ou 15 cm).
9.	 	 Legendas	das	figuras: numerar as figuras, em algarismos 
arábicos, na sequência de aparecimento no texto; editar as 
respectivas legendas, em espaço duplo, utilizando folha 
separada; identificar, na legenda, a figura e os eventuais 
símbolos (setas, letras etc.) assinalados; legendas de 
fotomicrografias devem, obrigatoriamente, conter dados 
de magnificação e coloração; reprodução de ilustração já 
publicada deve ser acompanhada da autorização, por escrito, 
dos autores e dos editores da publicação original e esse fato 
deve ser assinalado na legenda.
10. Outras informações: provas da edição serão enviadas aos 
autores, em casos especiais ou quando solicitadas, e, nessas 
circunstâncias, devem ser devolvidas, no máximo, em cinco 
dias; exceto para unidades de medida, abreviaturas devem 
ser evitadas; abreviatura utilizada pela primeira vez no texto 
principal deve ser expressa entre parênteses e precedida 
pela forma extensa que vai representar; evite utilizar nomes 
comerciais de medicamentos; os artigos não poderão apresentar 
dados ou ilustrações que possam identificar um doente; estudo 
realizado em seres humanos deve obedecer aos padrões éticos, 
ter o consentimento dos pacientes e a aprovação do Comitê 
de Ética em Pesquisa da instituição onde foi realizado; os 
autores serão os únicos responsáveis pelas opiniões e conceitos 
contidos nos artigos publicados, bem como pela exatidão das 
referências bibliográficas apresentadas; quando apropriados, 
ao final do artigo publicado, serão acrescentados comentários 
sobre a matéria. Esses comentários serão redigidos por alguém 
indicado pela Junta Editorial.
55 Analysis of intracranial aneurysms treated at a University Hospital in Curitiba
 Análise dos aneurismas intracranianos tratados em um Hospital Universitário de Curitiba
Johnni Oswaldo Zamponi Junior, Paulo Eduardo Carneiro da Silva, Guilherme Zandavalli Ramos, Guilherme Mailio Buchaim, 
Lucas Cunha de Andrade, Luis Fernando Macente Sala
61 Subdural arachnoidal cyst of the spinal cord: etiology, clinical 
presentation, surgical strategy and results
 Cisto aracnóideo subdural medular: etiologia, apresentação clínica, estratégia cirúrgica e resultados
Joelton Fonseca, José Carlos Lynch, Fabiana Policarpo, Celestino Esteves, Cleber Bomfim, Leonardo Welling 
68 Análise pós-operatória tardia da artrodese por via posterior em pacientes ASIA/
Frankel e com trauma raquimedular toracolombar em serviço universitário
 Postoperative late analysis of posterior arthrodesis in patients ASIA/
Frankel e with thoracolumbar spine trauma in university hospital
Tiago de Paiva Cavalcante, Siegfried Pimenta Kuehnitzsch, Emerson Oliveira Barbosa, Otacilio Moreira Guimarães, 
Gustavo Veloso Lages, George Santos dos Passos
75 Considerações sobre a síndrome da disfunção autonômica 
pós-traumatismo cranioencefálico: fisiopatologia e tratamento
 Dysautonomia after traumatic brain injury: physiopathology and treatment
Francisco Neuton Magalhães, Wellingson Silva Paiva, Almir Ferreira de Andrade, Edson Bor-Seng-Shu, Rodrigo Moreira Faleiro, 
Eberval Gadelha Figueiredo, Manoel Jacobsen Teixeira
81 Microsurgical anatomy of the anterior approach to the mesial temporal region
 Anatomia microcirúrgica do acesso anterior à região temporal mesial
Eberval Gadelha Figueiredo, Manoel Jacobsen Teixeira
86Resultados da lesão do trato de Lissauer e do corno posterior da medula espinal 
para o tratamento da dor neuropática central após lesão medular traumática
 Results of dorsal root entry zone (DREZ) lesioning for central 
neuropathic pain due to traumatic spinal cord injuries
Luis Roberto Mathias Júnior, Erich Talamoni Fonoff, Manoel Jocobsen Teixeira
91 Gliomas: marcadores tumorais e prognóstico
 Gliomas: tumors biomarkers and prognosis
Vinícius Trindade, Helder Picarelli, Eberval Gadelha Figueiredo, Manoel Jacobsen Teixeira
95 Granuloma eosinofílico da coluna vertebral cervical em criança
 Eosinophilic granuloma of the cervical spine in children
Rodrigo Moreira Faleiro, Luanna Rocha Vieira Martins, Geraldo Vítor Cardoso Bicalho
99 Hematoma subdural agudo infratentorial: relato de caso
 Posterior fossa acute subdural hematoma: case report
Leonardo Barnsley Araújo, Raul Starling de Barros, Bruno Freire de Castro
102 Hiper-hidrose em paciente com traumatismo raquimedular
 Hyperhidrosis in patient with spinal trauma
Carlos Umberto Pereira, Julianne Alves Machado
105 Síndrome de Turcot: relato de caso e achados da imunoistoquímica
 Turcot’s syndrome: case report and immunohistochemical findings
Emerson Brandão Sousa, Cléciton Braga Tavares, Igor Brenno Campbell Borges, Iruena Moraes Kessler 
Volume 31 | Número 2 | 2012
arquivos Brasileiros de Neurocirurgia
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Arq Bras Neurocir 31(2): 55-60, 2012
Analysis of intracranial 
aneurysms treated at a University 
Hospital in Curitiba 
Johnni Oswaldo Zamponi Junior1, Paulo Eduardo Carneiro da Silva2, 
Guilherme Zandavalli Ramos1, Guilherme Mailio Buchaim1, 
Lucas Cunha de Andrade1, Luis Fernando Macente Sala1
Hospital Universitário Evangélico de Curitiba, PR.
ABSTRACT
Objective: The aim of this paper is analyze the population and the types of intracranial aneurysms 
treated in the neurosurgery service of the Hospital Universitário Evangélico of Curitiba (HUEC), 
checking possible relations of this pathology with some risk factors and analyzing also the result of the 
treatment of this patients. Method: We reviewed the hospital files, surgical and out-patient notes of all 
patients operated on for the treatment of intracranial aneurysms from January 2006 to December 2010, 
composing a sample of 93 patients. The variables analyzed were gender, age, history of hypertension, 
smoking habit, diabetes mellitus, site of aneurysm, score scales Hunt-Hess and Fisher at hospital 
admission and treatment outcome of aneurysms using the Glasgow Outcome Scale (GOS). Results: 
The patients studied were predominantly women (73%), ranging in age from 51 to 60 years (38%), with 
a history of hypertension (61%). At admission, the grade 1 in a Hunt-Hess scale was most frequent 
(31%), while grade 4 on a scale of Fisher was more prevalent (26%). Aneurysms were more frequent 
in the anterior circulation, mainly affecting the middle cerebral artery. The most frequent score in GOS 
was 5 (40%). Conclusion: Subarachnoid hemorrhage is an event that may worsen the outcome of 
treatment of patients with intracranial aneurysms, so there is a correlation between the amount of 
bleeding identified on CT and prognostic evolution.
KEYWORDS
Intracranial aneurysms/classification, intracranial aneurysms/complications, risk factors, outcome and 
process assessment (health care), retrospective studies.
RESUMO
Análise dos aneurismas intracranianos tratados em um Hospital Universitário de Curitiba
Objetivo: O objetivo deste trabalho é analisar a população e os tipos de aneurismas intracranianos 
tratados no serviço de neurocirurgia do Hospital Universitário Evangélico de Curitiba (HUEC), verificando 
possíveis relações dessa patologia com alguns fatores de risco e analisando também o resultado do 
tratamento desses pacientes. Método: Foram revistos os prontuários e descrições de cirurgia de todos 
os pacientes operados para tratamento de aneurismas intracranianos no período de janeiro de 2006 
a dezembro de 2010, compondo uma amostra de 93 pacientes. As variáveis avaliadas foram gênero, 
idade, história de hipertensão arterial sistêmica, tabagismo, diabetes mellitus, local do aneurisma, 
pontuação das escalas de Hunt-Hess e Fisher na admissão hospitalar e o resultado do tratamento 
dos aneurismas utilizando a Escala de Prognóstico de Glasgow (GOS). Resultados: Os pacientes 
estudados foram predominantemente mulheres (73%), na faixa etária entre 51 e 60 anos (38%), com 
história de hipertensão (61%). À admissão hospitalar, o grau 1 na escala de Hunt-Hess foi mais frequente 
(31%), enquanto o grau 4 na escala de Fisher foi mais prevalente (26%). Aneurismas mais frequentes 
foram na circulação anterior, acometendo principalmente a artéria cerebral média. A pontuação na 
escala de GOS mais frequente foi 5 (40%). Conclusão: A hemorragia subaracnoide é um evento que 
pode piorar o resultado do tratamento de pacientes com aneurismas intracranianos, havendo, assim, 
uma correlação entre o volume de sangramento identificado na tomografia e a evolução prognóstica.
PALAVRAS-CHAVE
Aneurismas intracranianos/classificação, aneurismas intracranianos/complicações, fatores de risco, 
avaliação de processos e resultados (cuidados de saúde), estudos retrospectivos.
1 Acadêmico do Curso de Medicina da Faculdade Evangélica do Paraná (FEPAR) – Curitiba, PR, Brasil.
2 Neurocirurgião do Hospital Universitário Evangélico de Curitiba (HUEC) – Curitiba, PR, Brasil.
56 Analysis of intracranianial aneurysms treated at a University Hospital in Curitiba
Zamponi Jr JO et al.
Introduction
Intracranial aneurysms are classified as saccular, 
fusiform and dissecting. Approximately 90% are sac-
cular dilatations appearing as rounded or lobulated 
and protrusions that usually originate in the arterial 
bifurcations. It is generally considered acquired lesions 
resulting from prolonged hemodynamic stress and sub-
sequent degeneration at the level of local bifurcations 
and arterial branching. Regarding the size, intracranial 
aneurysms are divided according to their angiographic 
appearance, in: small (up to 12 mm), large (between 12 
and 25 mm) and giant (greater than 25 mm).1
The true incidence of cerebral aneurysms is un-
known, but it is estimated that these arterial dilations 
occur between 1%-6% of the population.2 It can occur 
multiple aneurysms, which are found around 20% of 
cases with a predominance in the female population.
Most aneurysms are asymptomatic and are diag-
nosed only after the break, which is a crucial aspect in 
the natural history of them. Ruptured aneurysms can 
not be found incidentally during the course of radiologi-
cal investigation for other pathologies. Subarachnoid 
hemorrhage (SAH) is the most common initial mani-
festation of ruptured aneurysms, and is considered a 
medical emergency, with high rates of morbidity and 
mortality when present. It is typically expressed by 
headache, neck stiffness and altered level of conscious-
ness, with headache as the most common symptom, 
present in up to 97% of cases, which is referred to by 
patients as the worst headache of your life. When there 
is a ruptured cerebral aneurysm is a sharp rise in intra-
cranialpressure, with levels of systolic blood pressure, 
this result in a decrease in cerebral perfusion pressure, 
resulting in a high reduction of cerebral blood flow. 
Rupture of an aneurysm can also cause bleeding within 
the brain parenchyma, ventricular system and even the 
subdural space and may cause the formation of an acute 
hydrocephalus due to changes in cerebrospinal fluid 
circulation, which may worsen the patient’s condition.3
Approximately one third of patients with ruptured 
aneurysms die before receiving medical care levels and 
mortality reaches 50% among the remaining patients. 
The incidence of subarachnoid hemorrhage due to 
rupture of aneurysms is estimated between 6 to 10 per 
100,000 individuals.4,5 Irregular multilobulated aneu-
rysms are more prone to breakage.
Kassel and Drake6 revealed that a total of 28,000 
ruptured aneurysms in North America, 18,000 survived 
the first episode, and of these only 9,000 fully resumed 
their previous activities, being only 40% returned to 
functional life despite modern treatment techniques.
Suzuki et al.7 ruled that the rupture usually takes 
place between the ages of 40 and 60 years, with peak 
incidence in the fifth decade, occurring rarely during 
childhood and adolescence. The rupture rate gradually 
increases until the sixth decade, when it reaches its 
peak and tends to decline to low levels after the eighth 
decade of life.
Besides the large number of patients with ruptured 
aneurysms, neurosurgeons frequently encounter 
patients who develop neurological deficits by mass 
effect due to the growth of intracranial aneurysms, or 
compression of cranial nerves or even focal cerebral 
ischemic symptoms related to embolization distal from 
thrombosed aneurysms, which occur mainly in large 
and giant aneurysms.
Regarding the etiology of this lesion, the literature 
shows that it is due to factors resulting from the asso-
ciation of congenital histological, hemodynamic, and 
degenerative diseases. Krex et al.8 found that several 
congenital factors were implicated in the pathogene-
sis of these lesions, such as defects in the media and 
elastic lamina, since the cerebral arteries lack external 
elastic lamina and intimal and medial layers are thin-
ner. Associated with this is the fact that the level of 
bifurcation of cerebral arteries there is less resistance to 
hemodynamic factors, since this level there will break 
in continuity of the middle layer, which allows direct 
contact between this layer and the adventitia, which 
with prolonged stress can cause a focal degeneration 
of internal elastic lamina favoring the formation of 
saccular aneurysms. This author also ruled that other 
factors also influence the synthesis of this injury, among 
them are: hypertension, diabetes mellitus, dyslipidemia, 
smoking, use of medications such as anticoagulants, and 
inherited diseases such as Ehlers-Danlos syndrome, 
Marfan syndrome, neurofibromatosis type I and II, 
and autosomal dominant polycystic kidney disease. 
Infiltration of blood, inflammation and necrosis due to 
infection may also cause weakness of the arterial wall 
and consequently aneurysm.
The methods for the evaluation of cerebral aneurysms 
include magnetic resonance angiography (MRA), CT 
angiography (CTA), ultrasound and transcranial Dop-
pler angiography with intra-arterial digital subtraction, 
the latter being considered the gold standard method.9
Methods
It was designed a retrospective study of patients 
with intracranial aneurysms treated by the Neuro-
surgical Service of Evangelical Hospital of Curitiba 
between January 2006 and December 2010, comprising 
a sample of 93 cases. The variables analyzed were sex, 
age, history of hypertension, diabetes mellitus, history of 
Arq Bras Neurocir 31(2): 55-60, 2012
57Analysis of intracranianial aneurysms treated at a University Hospital in Curitiba
Zamponi Jr JO et al.
alcoholism, smoking and aneurysm location. Patients 
with ruptured aneurysms were scored by Hunt-Hess 
scale for analysis of clinical conditions, and Fisher, 
for assessment of radiological evidence, which were 
measured in the same hospital admission. To analyze 
the results of treatment of intracranial aneurysms was 
used in the Glasgow Prognosis Scale (GOS), which was 
measured by monitoring the same patients over a period 
of three to six months after hospital discharge, enabling 
the analysis of the overall prognosis and the degree of 
disability established them.
Results
The analysis of the sample of 93 patients brought 
a significant prevalence of females; 68 people were 
women, representing 73% of the amount, and the male 
had a lower incidence (27%).
Regarding the age of these patients, the main age 
group affected was between 51 and 60, corresponding 
to approximately 38.7% of the total, followed by the 
range between 41 and 50, which corresponded to 24.7% 
of the sample. There were no cases under the age of 20 
years, and only 2 cases (2.1%) of patients 70 years or 
more (Figure 1).
Regarding the presence of single or multiple aneu-
rysms, 24 patients (26%) had multiple aneurysms, and 
74% had only one aneurysm. Due to the presence in 
some cases of multiple aneurysms have been well ana-
lyzed a total of 120 intracranial aneurysms.
With that being said about the location of these 
intracranial expansions, the main blood vessel in the 
sample affected was the middle cerebral artery (MCA) 
which was achieved in 44 cases (36.6%), followed by 
Figure 1 – Age of 93 cases reviewed.
aneurysms of the internal carotid artery (ICA) occur-
ring in 31 patients (25.8%). The arteries were the least 
affected were anterior cerebral artery (ACA) (3.3%) and 
basilar artery (BA) (2.5%) (Figure 2).
In evaluating the clinical status of patients at the 
entrance to the service using a scale of Hunt-Hess, the 
grade 1, characterized by a mild headache or a mild 
neck stiffness or even the asymptomatic patient, which 
was the most presented, corresponding 31,1%; followed 
by 26.8% with grade 2. The grade 5, characterized by a 
deep coma and the dying patient, was present in only 9 
cases (9.6%) (Figure 3).
In relation to the scale of Fisher score, which allowed 
the measurement of radiologic evidence of prior surgical 
procedures, the grade 4, characterized by intraventricu-
lar or intracerebral hemorrhage, was the most sentenced 
corresponding approximately 26.8%. The grade 1, found 
in patients with absence of hemorrhage on CT, cor-
responded approximately 24.7% of the total (Figure 4).
Regarding the prognosis of these patients, a group of 
38 people (40.8%) progressed to a good recovery after 
surgery, being able to return to their usual activities. The 
installation of a moderate disability, where the patient 
is capable of living independently but unable to return 
to work or school, was observed in 10 cases (10.7%). 
The presence of a severe deficiency, characterized by 
the individual who is able to follow commands but can 
not live independently, was sentenced in 13 patients 
(13.9%). Already a sample of 30 persons (32.2%) died, 
and in only 2 cases (2.1%) there was an evolution to a 
permanent vegetative state.
In the analysis of risk factors for intracranial aneu-
rysms, a total of 61.2% of cases had a history of hy-
pertension, and 15% had the habit of smoking. Other 
factors were less sentenced, as the presence of diabetes 
mellitus, present in 10% of the sample, and alcoholism, 
as evidenced in 4.3% of cases.
Arq Bras Neurocir 31(2): 55-60, 2012
58
Figure 2 – Location of intracranial aneurysm.
Figure 3 – Clinical analysis of patients using a scale of Hunt-Hess.
Figure 4 – Radiological analysis of patients through the scale of Fisher.
Analysis of intracranianial aneurysms treated at a University Hospital in Curitiba
Zamponi Jr JO et al.
Arq Bras Neurocir31(2): 55-60, 2012
59
Table 1 – Analysis of intracranial aneurysms in different populations
HUEC (2011) Lai et al. (2009) Ishibashi et al. (2009) Suzuki et al. (1971)
Total 93 266 419 3548
Sex
Male 25 (27%) 89 (33%) 139 (33%) 1916 (54%)
Female 68 (73%) 177 (67%) 280 (67%) 1614 (46%)
Aneurysms
Single 69 (74%) 222 (83%) 298 (71,1%) 3275 (92,3%)
Multiple 24 (26%) 45 (17%) 121 (28,9%) 273 (7,7%)
Localization
ICA 31 (26%) 23 (8,6%) 216 (41%) 1612 (41,3%)
ACA 4 (3%) 11 (4,1%) 107 (20%) 351 (9%)
MCA 44 (37%) 40 (15%) 141 (27%) 809 (20,8%)
AComA 17 (14%) 60 (22,5%) - 970 (24,9%)
PComA 21 (17,5%) 70 (26%) - -
BA 3 (2,5%) 15 (5,6%) 65 (12%) 156 (4%)
Discussion
The data obtained from our survey are very similar 
to the literature that says about the female be considered 
a “risk factor” for the formation and growth of cerebral 
aneurysms, because in our sample 73% of cases are 
women, having this predominance after 41 years. One 
hypothesis for this is based on the fact that with the 
decrease in plasma levels of sex hormones in post meno-
pausal women, there would be an inhibition of collagen 
formation, and thus can affect the brain blood vessels.10,11
The point prevalence of multiple aneurysms in 
our series was 26%, falling between the average sug-
gested by the literature, 17% to 30%. Studies say that the 
prevalence of multiple aneurysms changes according 
to the prevalence of risk factors for aneurysm forma-
tion in various populations.12,13 In our series there was 
a significant difference in the proportion of multiple 
aneurysms in men and women, with a high number of 
cases in females, showing that gender is an important 
risk factor for the formation of multiple aneurysms.
Among the risk factors studied have to consider 
mainly hypertension, which is present in 61% of our 
patients, which is extremely important for the develop-
ment, growth and rupture of cerebral aneurysms. Stu-
dies on the pathogenesis of atherosclerosis show a high 
tendency for hypertension to cause injury in the intima 
of the vessel, due to several factors, such as activation of 
apoptosis, and coagulation protein degradation,14 thus 
taking a high probability of causing change in wall the 
vessel, enabling the development of aneurysms. Another 
important risk factor is smoking, since it is present in 
14% of the sample. However, risk factors such as smo-
king, alcohol consumption and even atherosclerosis can 
not explain the development of aneurysms in young 
patients, which have a high mortality.
Concerning the location and redistribution of 
intracranial aneurysms, 80% occurred in the anterior 
circulation (carotid system) and approximately 20% was 
located in the posterior (vertebrobasilar system), this 
results were very similar to the literature; Suzuki et al.7 
ruled that about 87% occur in the anterior circulation 
and approximately 13% is located in the posterior re-
gion, it having around 95% of cases located in five major 
cerebral arteries, which are the internal carotid arteries, 
the anterior cerebral arteries, the arteries middle cere-
bral, vertebral arteries and basilar artery.
The middle cerebral artery (MCA) was the princi-
pal place of occurrence of cerebral aneurysms in our 
sample, occurring in 36% of patients. Other series bring 
different data, Lai et al.15 that analyzed 266 patients with 
intracranial aneurysms, and ruled that the vessel most 
commonly affected was the posterior communicating 
artery, with an incidence of 26%. On the other hand, 
Ishibashi et al.16 and Suzuki et al.7 have as intracranial 
artery most affected internal carotid artery (ICA), both 
with a percentage of 41% of the patients (Table 1).
The MCA aneurysms have typically a wide neck 
and its major branches emerge from the base and are 
housed inside the Silvius’s cistern. The bifurcation of the 
MCA is where it installs 90% of aneurysms of this artery, 
being one of the most affected by the atherosclerotic 
process, thus presenting a worse prognosis in cases of 
elderly patients.
The second main artery committed in our study was 
the internal carotid, representing 25% of intracranial 
aneurysms. The internal carotid artery aneurysms are 
mainly located at the point of bifurcation of this artery, 
because this location has a high hemodynamic stress, 
which weakens the vessel wall and promotes the forma-
tion of aneurysms. Thus, the swirling blood flow in the 
aneurysmal sac causes degenerative changes that weaken 
Analysis of intracranianial aneurysms treated at a University Hospital in Curitiba
Zamponi Jr JO et al.
Arq Bras Neurocir 31(2): 55-60, 2012
60
the wall of the aneurysm allowing the expansion of this ex-
pansion, increasing the possibility of rupture of the same.
Great series sentenced a high mortality and morbid-
ity in stroke patients with intracranial aneurysms with 
a mortality after 60 days around 50% and more than a 
third of victims had a permanent disability,17,18 our study 
has brought a lower mortality, revolving around 32%. In 
contrast, the International Cooperative Study on the Tim-
ing of Aneurysm Surgery, with a sample of 2,922 patients 
undergoing surgical treatment for ruptured intracranial 
aneurysms in 68 different centers around the world, 
reported a mortality of 14%, 69% of victims presenting 
between GOS 4 and 5.19 Osawa et al.20 analyzed 2,055 
patients treated in Japan, and sentenced a mortality of 
12.9%, one of the lowest found in the literature, also 
showing good results (GOS 4 to 5) in 68.5% of patients.
Conclusion
Despite the great progress in diagnostic tools, in-
tensive care, and advances in microsurgery and micro-
anatomy, intracranial aneurysms are still a major cause 
of death and disability in the practice of neurosurgery. 
Over time, it was possible to develop a reference stan-
dard and protocols for an expanded and appropriate 
management of patients with subarachnoid hemor-
rhage, thus enabling an optimal treatment for these 
patients in an attempt to reduce the high morbidity 
which are related with this pathology.
From the study we can see that our statistics are very 
similar to the data provided by the literature, showing 
satisfactory results in terms about the prognosis of pa-
tients when compared with other works, and conclude 
that subarachnoid hemorrhage is an event that can 
worse treatment outcome of patients with intracranial 
aneurysms, so there is a correlation between the amount 
of bleeding identified on CT and prognostic evolution.
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3. De Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing 
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12. Ellamushi HE, Grieve JP, Jäger HR, Kitchen ND. Risk factors 
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13. Juvela S. Risk factors for multiple intracranial aneurysms. 
Stroke. 2000;31(2):392-7. 
14. Stehbens WE. Apoptosis and matrix vesicles in the 
genesis of arterial aneurysms of cerebral arteries. Stroke. 
1998;29(7):1478-80. 
15. Lai HP, Cheng KM, Yu SC, Au Yeung KM, Cheung YL, 
Chan CM, et al. Size, location, and multiplicity of ruptured 
intracranial aneurysms in the Hong Kong Chinese 
population with subarachnoid haemorrhage. Hong Kong 
Med J. 2009;15(4):262-6. 
16. Ishibashi T, Murayama Y, Urashima M, Saguchi T, 
Ebara M, Arakawa H, et al. Unruptured intracranial 
aneurysms: incidence of rupture and risk factors. Stroke. 
2009;40(1):313-6. 
17. Becker KJ. Epidemiology and clinical presentation of 
aneurysmal subarachnoid hemorrhage. Neurosurg Clin N 
Am. 1998;9(3):435-44.
18. Shaffrey ME, Shaffrey CI, Lanzino G, Kassell NF. 
Nonoperative treatment of aneurysmal subaracnoid 
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4th ed. Philadelphia: Saunders; 1996. p. 1264-71.
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The International Cooperative Study on the Timing of 
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1990;73(1):37-47.
20. Osawa M, Hongo K, Tanaka Y, Nakamura Y, Kitazawa K, 
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Correspondence address
Johnni Oswaldo Zamponi Junior
Rua Padre Anchieta, 2670, ap. 1506 
80730-000 – Curitiba, PR, Brasil
Telefone: (044) 9973-3063
E-mail: johnni_zamponi@hotmail.com 
Analysis of intracranianial aneurysms treated at a University Hospital in Curitiba
Zamponi Jr JO et al.
Arq Bras Neurocir 31(2): 55-60, 2012
Arq Bras Neurocir 31(2): 61-7, 2012
Subdural arachnoidal cyst of the spinal 
cord: etiology, clinical presentation, 
surgical strategy and results
Joelton Fonseca1, José Carlos Lynch2, Fabiana Policarpo1, 
Celestino Esteves3, Cleber Bomfim1, Leonardo Welling1 
Neurosurgical Department of Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil.
ABSTRACT
Objective: Of this study is identifying the clinical manifestations, discuss the etiology, and present the 
surgical treatment nuances and outcomes of patients with sub dural arachnoidal cysts (AC). Method: 
A retrospective study was carried out with 7 consecutives patients with spinal cord subdural AC, 
diagnosed, evaluated and operated at the Neurosurgical department of Servidores do Estado Hospital, 
from 1996 to 2010. The radiological studies, patient records, surgical descriptions and surgical videos, 
were reviewed, creating a database from which information was collected. The follow-up varied from 2 to 
168 months (mean, 48 months). All cysts were histopathological verified. Results: Five AC were located 
on the thoracic spinal cord, one were located anterior in the cervical region, and one at the lumbar spinal 
level. The complete resection of the cyst was performed in 4 surgeries. Three patients had cysts located 
ventral to the cord, which precluded complete excision. The symptoms in four patients demonstrated major 
improvement. There was no operative death in this series, there was no major complications related to 
surgery. Conclusion: AC should be considered in the differential diagnosis of lesions causing myelopathy 
and/or a radicular pain syndrome. Microsurgical resection or generous fenestration in cysts effectively 
ameliorated patients’ symptomatology. 
KEYWORD
Arachnoid cysts, spinal cord compression, sciatica, myelitis, microsurgery. 
RESUMO
Cisto aracnóideo subdural medular: etiologia, apresentação clínica, estratégia cirúrgica e 
resultados
Objetivo: Identificar as manifestações clínicas, discutir a etiologia, apresentar as opções terapêuticas e 
revelar os resultados de uma série de pacientes diagnosticados com cisto aracnoide medular subdural 
(CA). Método: Realizamos um estudo retrospectivo em que analisamos 7 pacientes com AC que foram 
operados no Hospital dos Servidores do Estado, entre 1996 e 2010. Os estudos de imagem, prontuários, 
descrições cirúrgicas e os vídeos foram analisados e os dados, coletados. O seguimento variou de 8 a 168 
meses. Em todos os cistos foi realizado estudo histopatológico. Resultados: Cinco cistos se localizavam 
na medula torácica, um na cervical anterior e outro no segmento lombar. Obtivemos a excisão completa 
dos cistos em 4 pacientes, que apresentaram importante melhora dos sintomas. Não ocorreu nenhum 
óbito nessa série, nem piora do sintomas pré-operatórios. Conclusão: O CA deve ser considerado no 
diagnóstico diferencial das lesões que causam mielopatia ou síndrome radicular. A ressecção microcirúrgica 
ou uma ampla fenestração das paredes do cisto geralmente revertem os sintomas do pacientes.
PALAVRAS-CHAVE
Cistos aracnóideos, compressão da medula espinal, ciática, mielite, microcirurgia.
1 Resident of the Neurosurgical Department of Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil.
2 Head of the Neurosurgical Department of Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil.
3 Assistant of the Neurosurgical Department of Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil.
62 Subdural arachnoidal cyst
Fonseca J et al.
Introduction
Several different histological types of cysts located 
within or around the vertebral canal have been reported 
in the literature: aneurysmal bone cyst,1 cyst ligament,2 
synovial cyst,3,4 cysticercosis,5 neurenteric cyst,6 epen-
dimal cyst,7,8 arachnoiditis,8 and arachnoid cyst (AC). 
The subdural AC compressing the spinal cord is unu-
sual lesions. They frequently arise posterior to the spinal 
cord, most of them are located in the thoracic spine.9-20 
The majority of patients with a symptomatic intradural 
spinal AC have signs and symptoms of a myelopathic 
syndrome. AC should be considered in the differential 
diagnosis of lesions causing myelopathy and/or a radicu-
lar pain syndrome. Because for the aforementions reasons 
we decided reviewed our experience with this unusual 
lesion and present a clinical series, with 7 patients with 
spinal cord subdural AC, to identify the importance of the 
clinical manifestations, discuss the etiology, and present 
the surgical treatment nuances and outcomes.
Method
Patient population 
A retrospective study was carried out with 7 conse-
cutives patients with spinal cord subdural AC diagnosed, 
evaluated and operated at the Neurosurgical department 
of HSE, from 1996 to 2010. The Radiological studies, 
patient records, surgical descriptions, and when availa-
ble, surgical videos, were reviewed, creating a database 
from which information pertinent to the present study 
was collected. The follow-up included clinic visits and/
or telephone calls for patients from outside of Rio de Ja-
neiro. The follow-up varied from 3 to 168 months (mean, 
48 months). All cysts were histopathological verified.Surgical procedure 
In all cases, the same microsurgery technique was 
used. After general endotracheal intubation, the patient 
was placed in the prone position. A midline incision is 
made to expose longitudinally from the cranial to the 
caudal end of the cyst. The paravertebral muscles were 
elevated subperiosteally and laterally retracted, exposing 
the spinous processes and lamina of the corresponding 
vertebras. Removal of the laminas is performed. In one 
adolescent patient, to preserve the stability of the spi-
ne, we performed a laminotomy. In this situation, the 
lamina and spinous processes were removed as a single 
unit by lifting the spinous processes with an instrument 
and separating all ligamentous connections with small 
Kerrison rongeur. The laminae were replaced with mul-
tiple mini plates and screws. The surgical microscope 
is introduced, and using a 10 to 16x magnification the 
duramater is sectioned in midline, allowing access to 
intradural compartment. The free border of the du-
ramater is sutured in the paravertebral musculature. 
The cyst should be exposing it longitudinally from 
cranial to the caudal end. In 5 instances we found the 
AC located posterior or posterolateral to spinal cord, 
to be multilobulated by membranous trabeculae that 
bridged the most outer Arachnoid membrane and the 
vessels on the surface of the spinal cord. The cyst wall 
is fenestrated, the cerebrospinal fluid-like accumulated 
within the cyst, is gently aspirated and the cyst walls 
carefully ressected as much as possible, but without 
injury the neural elements. 
Following, we make a microlysis of the adhesions 
that involves the spinal cord and roots. The closure of 
the paravertebral musculature and fascia is performed 
in 3 layers; the skin is sutured with 3.0 nylon.
Illustrative case
An 8-year-old girl developed a progressive walking 
difficulties. The neurological examination revealed a 
paraparesis; increase deep tendon reflexes and bilateral 
Babinski. Chest XR showed a thoracic scoliosis. MRI re-
vealed a cystic lesion with signal characteristics similar 
to CSF at T2-T10 compressing anteriorly the spinal cord, 
for which she underwent laminotomy with extensive 
removal of the thin-walled cyst wall. The medulla was 
depressed but started immediately with a good pulsa-
tion. She made an uneventful recovery after surgery 
and retour to her normal life (Figures 1A, B, C, D e E).
Figure 1A – Chest X-ray detecting a thoracic scoliosis.
Arq Bras Neurocir 31(2): 61-7, 2012
63Subdural arachnoidal cyst
Fonseca J et al.
Figure 1B – Cervical MRI showing a large posterior 
cervicothoracic cyst lesion, located posterior to the spinal cord. 
Note the ventral displacement and deformation of the spinal cord.
Figure 1C – Operative photograph showing the thin cystic 
arachnoid layer and the depressed spinal cord.
Figure 1D – Operative image of the fusion of laminothomy with 
mini plates.
Figure 1E – Hystology of the cyst lesion wall revealing collagenous 
fibers membranes and an inner layer cuboid cells. 
(H/E – 50X)
Results 
 In this series, there were 3 men and 4 women ran-
ging in age from 8 to 44 years, average of 30.2 years. The 
duration of the symptoms varied from 1 to 36 months 
years (Table 1). In these, series all patients have signs 
and symptoms of a myelopathic syndrome and in 4, 
added radicular pain (Table 1). 
The signs and symptoms are listed in the table 1. 
Four AC were located on the thoracic spinal cord, 1 
were located anterior in the cervical region, and 1 at the 
posterior lumbar spinal level. Craniocaudal extension 
of dorsal Arachnoid cysts varied from 2 to 8 vertebral 
levels (mean, 4.4 vertebral levels). Complete resection of 
the cyst was performed in 4 surgeries, all of whom had 
cysts situated dorsal or dorsolateral to the cord. Three 
patients had cysts located ventral to the cord, which 
precluded complete excision; therefore, they were wide 
open and marsupialized to the subarachnoid space. 
Histopathological examination revealed Arachnoid 
cysts, in all cases (Figure 1E). Symptoms in 4 patients 
demonstrated major improvement; there was no cyst 
recurrence on MRI after a mean follow-up period of 3.2 
years. The follow-up varied from 0.3 to 12 years with 
an average of 5.7 years. There is no operative death in 
this series, there were no major complications related 
Arq Bras Neurocir 31(2): 61-7, 2012
64
to surgery. None of these patients deteriorated after 
surgery. Two of the 7 patients with preoperative pain 
had significant improvement after surgery. During the 
follow up, we observed that 4 patients had an excellent 
or good early postoperative result, 2 had a fair result, 
Table 1 – Signs, symptoms, ethiology, surgery and outcome of 7 cases with subdural thoracic AC
Patients Age (Yr)/Sex Trauma Clinical 
presentations
Level Evolution time 
(months)
Surgery Site Follow-up
1 16/M Yes Paraparesis T10-T11 24 Laminectomy/
Cyst removal
Posterior Normal
2 44/M No Paraparesis T8-T9-T10 2 Laminectomy/
Cyst removal
Posterolateral Normal
3 37/F No Pain/Paraparesis T11-S1 36 Laminectomy/
Fenestration
Posterolateral No change
4 47/F Yes Pain/
Paraparesis
T9-T10 7 Laminectomy/
Fenestration
Posterolateral No change
5 O8/F No Pain/Paraparesis T2 a T10 12 Laminotomy/
Cyst removal
Posterior Normal
6 18/M Yes Paraplegya C2-C3 1 Laminectomy/
Fenestration
Anterial No change
7 42/F No Paraparesis T5-T12 13 Laminectomy/
Cyst removal
Posterolateral Normal
Figure 2B – Operative photographs showing a subdural cyst, 
hypertrophic meninge, aracnoditis and proliferative exsudate.Figure 2A – Sagital T2 RMI detecting an anterior lumbar cyst.
and no improvement was noticed in one patient with 
long-standing myelopathy, with evidence during sur-
gery, of adhesive arachnoiditis and atrophy of the spinal 
cord (Figures 2A and B). One of these 8 patients was 
lost in the follow-up. 
Subdural arachnoidal cyst
Fonseca J et al.
Arq Bras Neurocir 31(2): 61-7, 2012
65
cells degenerate, and increased pressure builds up within 
the cyst.16,17,23 Fortuna et al.22 have proposed that all 
types of Arachnoid diverticula result from hypertrophy, 
proliferation, and dilatation of arachnoid granulations. 
They theorized that if the dilatation were confined by a 
resistant dura, a subdural cyst would result, whereas a 
weakened or deficient dura would allow herniation of 
the Arachnoid along the path of least resistance into the 
epidural space to form an extradural cyst. 
Neuroimaging studies
The primary MRI finding suggestive of this lesion is 
a subdural extramedullary space-occupying lesion. The 
cysts demonstrated signal characteristics similar to CSF, 
being of low intensity on T1-weighted images and pro-
gressing to high intensity with T2-weighting (Figures 1B 
and 2A). All cysts, but two, were sufficiently delineated 
by MRI, including their location in relation to the spinal 
cord and their craniocaudal extension. Myelography 
is no longer routinely performed at our institution for 
preoperative diagnostic workup but the two first patients 
of this series were diagnosed by this method. Accord 
to Shimizu et al.27 the Cardiac cine magnetic study can 
provide valuable information for the evaluation of spinal 
subdural AC. First, the visualization of abnormal flow 
provides a more robust evidence of the presence of a 
cystic formation and may indicate the location of the 
cystic wall or septum to be opened surgically. Second, 
dynamic spinal cord compression by the cyst can also be 
shown. Unfortunately, this technology was not avaible 
for use in this series.
Patient management
Several authors believed that the primary indi-
cations for surgical intervention are pain that do not 
respond to conservative therapy and/or neurologicaldeficit.13,17,21-23,28,29 
The majority published series showed the benefits of 
total excision of AC, however, in the cases that this is not 
feasible because fibrous adhesion of the wall of the cyst 
to neural structures or the anterior location in relation 
to spinal cord, a partial resection or fenestration should 
be performed as widely as possible13,17,21-23,29 (Table 2). 
From a technical point of view, not only one, but several 
stomas should be performed between the cyst and the 
subarachnoid space, as in order to reduce the risk of late 
closure and recurrence and obtain a free communica-
tion from the cyst to the normal subarachnoid space.
The treatment of a total or partial resection of cyst 
wall or fenestration produced an excellent return of 
neurological function in 4 of ours 7 patients.
Discussion
There are some limitations to this study. First, it is 
subject to all the biases of retrospective studies. Second, 
because no effort was made to randomize patients to 
various management paradigms, it simply presents 
our experience with these lesions, especially on the 
importance of performing whenever possible a total 
excision of AC, or a wide fenestration to ensure a near to 
physiological cerebrospinal fluid circulation and reduce 
the risk of recurrence. 
Pathogenesis
Spinal AC has been termed by various authors 
as “arachnoid diverticula”, “leptomeningeal cysts”, 
“localized adhesive arachnoiditis”, and “serous spi-
nal meningitis” subarachnoid cysts, and meningeal 
hydrops13,15-17,21 according to different pathogenetic 
conceptions. The origin of spinal intradural AC is not 
always clear. Several hypotheses have been proposed to 
explain the formation of intradural AC, some lesions 
develop because of infection (case 4), trauma (case 3 
and 6), surgery, subarachnoid hemorrhage, lumbar 
puncture, or neural tube defects; however, the majority 
of cysts are thought to be congenital or idiopathic, 
cases (1, 2, 5, 7 and 8).12,13,16,17,21-24 Some authors have 
observed intramedullary cavitations or a syrinx con-
comitant with an intradural arachnoid cyst. Osenbach 
et al.21 observed a single case Klippel-Feil anomaly 
and cervical diastematomyelia among 11 patients 
harboring an intradural arachnoid cyst. Associated 
vertebral anomalies, most commonly kyphoscoliosis, 
were described in 71% of the patients in the series of 
Alvisi et al.25. Our case number 5 presents a thoracic 
kiphoscoliosis (Figure 1A). Table 1 showed the signs, 
symptoms; type of surgery and out come of 7 patients 
treated by our group.
The primary cyst seems to arise during develop-
ment and, although present at birth, may expand and 
progressively compress the spinal cord and/or the roots. 
The majority of AC is located in the posterior aspect 
of thoracic spine.21 Perret et al.20 suggested that the AC 
arise from “diverticula” of the arachnoidal membranes, 
particularly from the relatively well-developed arach-
noidal septum between the posterior dura and dorsal 
spinal cord (septum posticum). Although Perret’s theory 
adequately explains dorsal cysts, it fails to account for 
those in a ventral location. Teng and Rudner26 proposed 
that normal daily variations of intraspinal CSF pressure 
lead to cyst formation through dilatation of low resis-
tance areas within the Arachnoid. The pathological 
distribution of the Arachnoid trabeculae at areas with 
lower resistance, leads to a diverticulum. The trabecular 
Subdural arachnoidal cyst
Fonseca J et al.
Arq Bras Neurocir 31(2): 61-7, 2012
66
Table 2 – Summary of literature on spinal intradural arachnoidal cyst
Series
Ref. nº
Nº of
patients
Age (mean) Origin Extension
(levels)
Surgical technique Results
(%)
F/U
(YR)
Palmer JJ (18), 1974 5 19.3 Idiopathic = 4 3.4 Ressection = 1
Fenestration = 4
Improve
80%
5.5
Osenbach RK et al. (21), 1992 11 41 Idiopathic = 9 3.4 Ressection = 8
Fenestration = 3
Improve
64.4%
2
Kazan S et al. (10), 1999 2 16.5 Trauma = 1
Idiopathic = 1
2 Ressection = 1
Fenestration = 1
Improve
100%
1
Chen HJ and Chen L (12), 1996 1 18 Traumatic 3 Fenestration Improve
100%
N/A
Shimizu H et al. (27), 1997 4 35 Idiopathic 4.5 Ressection Improve
100%
1.8
Paramore GG (19), 2000 2 49.5 Idiopathic 5 Ressection = 2 Improve
100%
N/A
Tumialán et al. (8) 2005 1 53 SAH 2 Fenestration Improve
100%
0.7
Sharma et al. (29), 2005 1 4 Idiopathic 6 Ressection Improve
100%
1.5
Endo T et al. (30), 2010 6 38.7 Idiopathic = 4
Infection = 1
Traumatic = 1
7.6 Endoscopy 
Fenestration
Improve 
100%
9.5
Present series 2011 7 30.2 Idiopathic = 5
Traumatic = 2
4.4 Ressection = 5
Fenestration = 2
Improve
85,7%
5.7
Osenbach et al.21 experienced deterioration of symp-
toms within 1 year after surgery, without evidence of 
cyst recurrence on follow-up MRI. It may be attributa-
ble to progressive myelomalacia secondary to vascular 
compromise and chronic ischemia of the spinal cord. 
Recently, Endo et al.30 proposed the use of endoscopy to 
treat the AC as a less invasive surgical exposure. 
This current experience of 8 individuals with AC 
with total surgical excision or a wide fenestration of the 
walls of the AC and microlysis of adhesions of spinal 
cord proved a safe surgery without mortality and effec-
tive procedure with symptomatic improving of 57.1%, 
result similar to others published series in the literature 
Conclusion
We can assert that intradural AC is rare lesions. 
The majority of patients with a symptomatic intradural 
spinal AC have signs and symptoms of a myelopathic 
syndrome. AC should be considered in the differen-
tial diagnosis of lesions causing myelopathy and/or 
a radicular pain syndrome. Preoperative diagnostic 
workup of these lesions and postoperative follow-up is 
best accomplished by MRI. Microsurgical resection or 
generous fenestration in cysts effectively ameliorated 
patients’ symptomatology. 
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Correspondence address 
José Carlos Lynch
Rua Jardim Botânico, 600/605
22461-000 – Rio de Janeiro, RJ, Brazil
Telefone: (021) 2294-1937
E-mail: cneuroamericas@uol.com.br
Subdural arachnoidal cyst
Fonseca J et al.
Arq Bras Neurocir 31(2): 61-7, 2012
Análise pós-operatória tardia da 
artrodese por via posterior em 
pacientes ASIA/Frankel e com 
trauma raquimedular toracolombar 
em serviço universitário
Tiago de Paiva Cavalcante1, Siegfried Pimenta Kuehnitzsch1, Emerson Oliveira Barbosa2, 
Otacilio Moreira Guimarães3, Gustavo Veloso Lages4, George Santos dos Passos5
 Hospital Universitário Alzira Velano – Alfenas, MG, Brasil.
RESUMO
Objetivo: O propósito deste estudo foi avaliar retrospectivamente o tratamento cirúrgico de pacientes 
vítimas de trauma raquimedular desse segmento sem déficit neurológico, quanto à evolução da dor local 
e à deformidade cifótica local e regional do segmento acometido, em um serviço universitário. Método: 
Foram utilizados dados de prontuário e avaliações clínicas e radiológicas de 16 pacientes submetidos 
à artrodese pedicular por via posterior, no período de maio de 2003 a dezembro de 2006, operados há 
pelo menos dois anos. Resultados: A média de idade foi de 43,43 ± 11,44 anos e o nível mais acometido 
L1. O mecanismo principal do trauma foi queda de altura. Após realização de raios X em perfil e cálculo 
dos ângulos local sagital (ALS) e regional sagital (ARS), de pós-operatório precoce e tardio, não houve 
diferença estatisticamente significativa entre os dados obtidos, apesar da diminuição de -15,3º para -10,7º 
nas cifoses locais e do aumento de -13,7º para 15,9º nas cifoses regionais. Houve diferença estatística 
na avaliação de dor pela Escala Analógica de Dor (EAD), entre o pré-operatório e o pós-operatório tardio 
(maior que dois anos), com redução de quatro vezes da intensidade da dor entre os pacientes analisados 
(p < 0,05). Conclusão: A artrodese pela via posterior é uma proposta alternativa de tratamento quando 
se discute a dor desses pacientes. Fica a necessidade de abranger um número maior de pacientes com 
essa patologia, a fim de dispor dados mais fidedignos, respaldando o tratamento como uma alternativa 
viável no manejo de pacientes com fraturas toracolombares e neurologicamente intactos.
PALAVRAS-CHAVE
Traumatismos da coluna vertebral, artrodese, traumatismos da medula espinal/cirurgia. 
ABSTRACT
Postoperative late analysis of posterior arthrodesis in patients ASIA/Frankel e with 
thoracolumbar spine trauma in university hospital
Objective: The aim of this study was a retrospective valuation of surgical treatment of patients with spinal 
thoracolumbar spine without neurological deficit, for that local pain, local and regional kyphotic deformity 
at an university hospital. Method: There were used hospital datum from 16 operated patients and clinical 
and radiological evaluation submitted a pedicular screw instrumentation from May 2003 until December 
2006, operated for at least 2 years. Results: The mean age was 43.43 ± 11.44 years and the most fractured 
level L1. The principal mechanism was height fall. After the x-rays realized and calculated the local sagittal 
angle and regional sagittal angle, there’s no significative difference between them, despite the reduction 
of -15.3º to -10.7º, at local kyphosis and augmentation of -13.7º to 15.9º at regional kyphosis. There was 
statistics difference at pain evaluation using the Analogic Pain Scale, between the pre-operative and 
postoperative (beyond two years), with four times reduction of intensity pain among the analyzed patients 
(p < 0.05). Conclusion: The arthrodesis by posterior approach is an alternative proposal of treatment 
when discussing the pain of these patients. It is the need to include a larger number of patients with this 
pathology, in order to dispose more data reliable, endorsing the treatment as a viable alternative in the 
management of patients with thoracolumbar fractures and neurologically intact.
KEYWORDS
Spinal injuries, arthrodesis, spinal cord injuries/surgery. 
1 Neurocirurgião da Fundação de Neurologia e Neurocirurgia – Instituto do Cérebro, Salvador, BA; ex-residente do Hospital Universitário Alzira 
Velano (HUAV), Alfenas, MG, Brasil.
2 Neurocirurgião e ex-preceptor da residência de neurocirurgia do HUAV, Alfenas, MG, Brasil.
3 Neurocirurgião chefe da residência de neurocirurgia do HUAV, Alfenas, MG, Brasil.
4 Residente de neurocirurgia do HUAV, Alfenas, MG, Brasil.
5 Acadêmico de medicina da Escola Bahiana de Medicina e Saúde Pública, Bahia, Brasil.
Arq Bras Neurocir 31(2): 68-74, 2012
69Artrodesepor via posterior em pacientes ASIA/Frankel e com trauma raquimedular toracolombar
Cavalcante TP et al.
ou sem cisalhamento anterior. No tipo C há uma rotação 
e associação com os outros tipos de fratura, A ou B.6 
Apesar de as fraturas do tipo A pela classificação 
AO serem as mais frequentes (66%)6, continuam sendo 
as que mais despertam opiniões divergentes quanto ao 
seu manejo. Não há dúvida de que, em pacientes com 
deterioração neurológica progressiva, a descompressão 
neurocirúrgica está indicada.7 Fraturas com mais de 
50% de colapso do corpo anterior da vértebra, ou com 
mais de 20º de angulação sagital ou mais de 40%-50% 
de comprometimento do canal vertebral no nível da 
fratura em pacientes neurologicamente intactos, são 
todos critérios para tratamento cirúrgico, uma ma-
neira indireta de indicar a perda da tensão da coluna 
posterior e, portanto, da estabilidade sagital da coluna 
toracolombar.1,3,7-10 
As instrumentações pediculares curtas são as mais 
utilizadas e difundidas para abordagem cirúrgica pos-
terior das fraturas toracolombares ao redor do mundo. 
Realizadas com um nível acima e outro abaixo, com 
colocação de um parafuso através do pedículo das 
vértebras íntegras, procuram restabelecer o balanço 
sagital e estabilizar a fratura, limitando o número de 
segmentos instrumentados ao mínimo necessário, uma 
vez que não há diferenças entre construções com dois 
níveis acima ou abaixo destas.7
A importância do estudo desse assunto está no 
fato de que ainda não há concordância total quanto ao 
tratamento ideal desses pacientes, principalmente no 
pós-operatório tardio.
Figura 1 – Classificação das fraturas toracolombares adotada pela AOSpine, segundo os critérios de Magerl (com permissão).
Introdução
Os traumas na região da coluna vertebral compreen-
dem uma parcela significativa da população, além de 
promover altos custos à sociedade. Estima-se que nos 
Estados Unidos existam 150.000 pessoas incapacita-
das vítimas de algum trauma vertebral e que 10.000 
novos casos se adicionem a esse grupo por ano.1,2 
Ao se considerar a coluna toracolombar, o segmento 
mais acometido é o da junção toracolombar (T11-L1), 
seguido pelos níveis torácicos (T1-T10) e lombares 
(L2-L5).3 Passagem de uma área de menor para de 
lares a partir de T11, permitindo maior movimento 
nesse plano e aumentando a resistência rotacional em 
relação à coluna torácica com suas facetas articulares 
num plano coronal, são fatores da maior incidência de 
fraturas nessa região.4,5 Adicione-se a isso a menor força 
que os ligamentos longitudinais posteriores e amarelo, 
e as facetas articulares em relação à coluna lombar. As 
lesões medulares nesse segmento podem afetar a medula 
espinhal baixa, cone medular e cauda equina, com uma 
variedade de lesões de prognósticos diversos. 
Seguindo os critérios de estabilidade/instabilidade 
da AOSpine (Figura 1), as fraturas do tipo A são deriva-
das de uma força de compressão axial, associada ou não 
à flexão, mantendo intactos os ligamentos posteriores, 
portanto não havendo movimentação no plano sagital. 
As fraturas do tipo B e seus subtipos envolveriam um 
mecanismo de flexão-distração com rotura e alonga-
mento dos elementos posteriores, ou hiperextensão com 
Força de compressão Força de tensão Torque axial
Lesões com traço de 
ruptura transverso
Lesões rotacionaisFraturas por compressão 
e explosão
Tipo A – Compressão
A.1 – Fraturas impactadas
 A.1.1 – Impactação da placa terminal
 A.1.2 – Encunhamento
 A.1.3 – Colapso do corpo vertebral
A.2 – Split (separação)
 A.2.1 – Sagital
 A.2.2 – Coronal
 A.2.3 – Pinça 
A.3 – Explosão
 A.3.1 – Incompleta
 A.3.2 – Explosão-separação
 A.3.3 – Completa
Tipo B – Lesão por distração
B.1 – Lesão posterior ligamentar
 B.1.1 – Com rotura transversa do disco
 B.1.2 – Associada à fratura do tipo A
B.2 – Lesão posterior óssea
 B.2.1 – Fratura transversa da vértebra (Chance)
 B.2.2 – Espondilólise com lesão do disco
 B.2.3 – Espondilólise com fratura do tipo A
B.3 – Lesão anterior – Hiperextensão
 B.3.1 – Hiperextensão-subluxação
 B.3.2 – Hiperextensão-espondilólise
 B.3.3 – Luxação posterior
Tipo C – Rotação
C.1 – Lesão tipo A + rotação
 C.1.1 – Impactada
 C.1.2 – Separação
 C.1.3 – Explosão
C.2 – Lesão tipo B + rotação
 C.2.1 – Lesão B.1 + rotação
 C.2.2 – Lesão B.2 + rotação
 C.2.3 – Lesão B.3 + rotação
C.3 – Cisalhamento-rotação
 C.3.1 – Fratura do tipo slice
 C.3.2 – Fratura oblíqua
Arq Bras Neurocir 31(2): 68-74, 2012
70
Materiais e métodos
Estudo retrospectivo de 16 pacientes vítimas de 
traumatismo raquimedular no segmento de T10-L2, 
sem déficits neurológicos, submetidos à artrodese cirúr-
gica por via posterior, no período entre maio de 2003 e 
dezembro de 2006, operados há pelo menos dois anos. 
Os pacientes foram incluídos seguindo os seguintes 
critérios, baseados em Siebenga et al.11: fratura trau-
mática de T10-L2, tipo A pela AO (compressão), com 
acunhamento anterior maior que 50% e/ou cifose maior 
que 20º e/ou estenose de canal vertebral maior que 40%, 
sem déficit neurológico (ASIA/Frankel E), período de 
pós-operatório não inferior a dois anos.
Os critérios de exclusão foram fratura tipo A.1.1 
pela AO, gestação, fratura patológica ou osteoporótica, 
pacientes com doença terminal, pacientes com história 
de cirurgia prévia na coluna, pacientes com histórico 
psiquiátrico recente, pacientes em uso de drogas ou 
outras substâncias ilegais, ou pacientes apresentando in-
júria que pudesse interferir com o tratamento proposto. 
O trabalho foi submetido à comissão de ética do hospital 
e todos os pacientes foram informados e consentiram.
Os pacientes foram submetidos a um questionário 
próprio, que avaliava dados demográficos como idade, 
mecanismo da lesão, segmentos lesionados e fixados 
cirurgicamente e dados sobre evolução da dor no local 
fraturado no período e aplicados na Escala Analógica 
Visual de Dor. Continha, ainda, dados coletados em 
exames de imagem do pós-operatório imediato (menor 
que três meses) e exames de imagem do pós-operatório 
tardio (maior que dois anos), relacionando informações 
dos ângulos locais e regionais nos segmentos afetados. 
Avaliação clínica e método cirúrgico
Após a admissão e o estudo radiológico completo 
com radiografias de coluna toracolombar em incidên-
cias anteroposterior e perfil e tomografia de coluna 
helicoidal (Figura 2), os pacientes vítimas de trauma-
tismo raquimedular com fratura no segmento T10L2 
e indicação neurocirúrgica, sem déficit neurológico, 
foram submetidos à abordagem cirúrgica precoce. 
Seguindo a técnica descrita e consagrada na literatura, 
foi realizada laminectomia do nível/níveis fraturados e 
fixados parafusos pediculares um ou dois níveis acima 
ou abaixo e conectados a barras de fixação longitudinais 
e, sempre que possível, inserida barra de fixação trans-
versal. Foi realizado enxerto autólogo ósseo retirado das 
laminectomias sobre o trajeto das barras longitudinais, 
especialmente nos pontos de inserção do parafuso 
pedicular. A alta hospitalar ocorreu em 3-4 dias, sem 
dor e após raios X de controle, para acompanhamento 
ambulatorial especializado. Foi prescrita fisioterapia 
motora para todos os pacientes, e estes não utilizaram 
colete de Jewite no pós-operatório.
Realizou-se acompanhamento ambulatorial de neu-
rocirurgia, em pelo menos dois anos de pós-operatório. 
Na Escala Analógica de Dor, o valor 0 foi dado para dor 
inexistente e 10 para a maior dor possível. Solicitados raios 
X de coluna toracolombar em perfil neutro e dinâmico em 
flexão e extensão (Figuras 3 e 4). Os exames em flexão/
extensão foram realizados com o paciente em ortostatismo 
Figura 2 – Imagem de tomografia computadorizada de paciente 
vítima de trauma raquimedular (com autorização).
Figura 3 – Imagem de raios X de PO imediato de artrodese