The Middle Meningeal Artery: Branches, Dangerous Anastomoses, and Implications in Neurosurgery and Neuroendovascular Surgery

Abstract

The middle meningeal artery (MMA) has always been the workhorse corridor for devascularization of dural-based intracranial lesions and, more recently, has been established as a target for the endovascular management of chronic subdural hematomas. The MMA anatomy is complex and deceitful, and its territory of irrigation (including cranial nerves) is poorly understood. Furthermore, MMA variations and anastomoses are more frequent than expected, which may predispose to procedure-related morbidity. A literature search was conducted in electronic databases per PRISMA guidelines for studies describing normal and abnormal MMA anatomy including variations in MMA origin and dangerous anastomoses. Our institutional case series of greater than 100 MMA embolizations for management of chronic subdural hematomas were reviewed for abnormal MMA anatomy, and clinically relevant case examples are presented. In this article, we provide a comprehensive review of the MMA to provide a better understanding and appreciation of this artery, including pearls and pitfalls, that we hope will aid the neurosurgeon and neurointerventionalist in safely tackling these lesions.

Ischemia of the parotid gland and adjacent muscles of mastication following middle meningeal artery embolization

“…7,8 Therefore, the course of cSDH is determined by a repeated cycle of bleeding and absorption through the cSDH membrane that arises from the distal branches of the MMA. 9 According to the results of other studies, [9][10][11] spontaneous resolution is rare, which suggests that bleeding exceeds absorption in the majority of cases. No effective nonsurgical treatment has been developed; many surgeons prefer surgical removal, even of asymptomatic hematomas.…”

“…The MMA anatomy is quite complex with numerous variations and anastomoses occurring frequently. 11,12 Multiple studies demonstrate the variability of MMA anatomy and emphasize the importance of avoiding potential ophthalmic collaterals and branches supplying cranial nerves. 13,14 The vascular supply of the whole parotid gland is through the branches of the ECA: the posterior auricular artery (posterior part), the superficial temporal artery (a small part of the gland at the top), and its branch transverse facial artery (upper anterior part of the gland).…”

“…Embolization of the MMA has recently been proved to be a minimally invasive and efficacious treatment alternative to surgery for cSDH in several studies. 7,10,11,13,14 Even with the low risk of endovascular procedures, it is important to avoid complications. Middle meningeal artery angiogram should be carefully reviewed prior to the procedure to identify dangerous ophthalmic anastomoses from the orbital/ meningolacrimal branch and/or prominent petrosal branches that could lead to injury to the facial nerve, or temporal branches that could lead to injury of the parotid gland and the muscles of mastication.…”

Characterization of non-human primate dura in health and neurodegeneration

“…12,15,17 In terms of surgical interventions, MMA embolization is an established endovascular approach to management of meningeal tumors and chronic subdural hematomas. 58 However, there are individual variations in anatomy and anastomoses that pose risk for the procedure and the normal role of MMA is still not well-understood. 59 MMA enters the skull and branches into anterior and posterior branches.…”

Pharyngo-tympano-stapedial middle meningeal artery variant supply to a falcotentorial dural arteriovenous fistula

“…including subdural hematomas, spontaneous and traumatic dural arteriovenous fistulas, dural arterial supply to arteriovenous malformations, and pseudoaneurysms 1 2. Its anatomic course is clinically significant as there are ‘dangerous connections’ to the eye via meningolacrimal or meningo-ophthlamic anastomoses as well as to the branches of the inferolateral trunk of the internal carotid artery in the region of the cavernous sinus 3. Typically, the middle meningeal artery is safe to embolize beyond these dangerous connections.…”