Elsevier

World Neurosurgery

Volume 133, January 2020, Pages 84-89
World Neurosurgery

Case Report
Anomalous “Middle” Meningeal Artery from Basilar Artery and Implications for Neuroendovascular Surgery: Case Report and Review of Literature

https://doi.org/10.1016/j.wneu.2019.09.130Get rights and content

Background

The middle meningeal artery (MMA) is an important conduit for the endovascular treatment of skull base and intracranial pathologies including, recently, subdural hematomas. A key aspect of such procedures is to perform a thorough diagnostic angiogram to detect anomalous arterial origins and “dangerous” anastomoses with branches of the internal carotid arteries. Although the most common anomaly related to the MMA is an abnormal origin from the ophthalmic artery, anomalous origin from the posterior circulation is rare. Moreover, its recognition requires a concerted effort at performing a vertebral artery angiogram irrespective of the location of the pathology (e.g., in subdural hematoma).

Case Description

We describe a case of anomalous origin of MMA from the basilar artery as a lateral pontine artery branch that was detected in a patient with recurrent subdural hematoma who presented for endovascular MMA embolization.

Conclusions

The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolization.

Section snippets

Background and Importance

The middle meningeal artery (MMA) and its branches are regularly catheterized to deliver embolic agents in treating dural arteriovenous fistulas and tumors. Recently MMA embolization has been performed for subdural hematomas.1 The prerequisite for embolization is performing a thorough diagnostic angiogram in order to detect dangerous anastomoses and anatomic variations that may impact therapeutic decisions. One example is the anomalous origin of MMA. Here we present a patient with subdural

Methods: Literature Review

We performed a systematic literature review in PubMed with key words “(middle meningeal artery) AND (origin OR anastomosis OR abnormal OR variant OR variation OR anomalous) AND (basilar).” Twenty-six papers resulted, of which 20 were excluded (9 non English, 11 nonrelevant). Six papers reporting 9 cases with a total of 10 arteries were found. One additional paper describing 1 case with 1 artery was found from cross references.

Clinical Presentation

An 82-year-old gentleman on aspirin with a recurrent left-sided chronic subdural hematoma (Figure 1) presented for MMA embolization. Left external carotid artery injection revealed an MMA arising from the internal maxillary artery (IMAX) that, after entering the middle fossa floor, continued in the distribution of the posterior division of MMA (Figure 2A and B). Vertebral artery injection revealed an unusual left pontine artery branch of the basilar artery arising below the superior cerebellar

Literature Review

Table 1 provides an overview of pertinent papers. Most described cases were unilateral. The left side was commonest (7 vs. 4 on right). The majority were detected on angiography performed for diagnostic reasons. One was detected during attempted embolization of an extraaxial tumor. The anomalous artery was not used for embolization. Our case was diagnosed during targeted MMA embolization for subdural hematoma.

Embryology of Middle Meningeal Artery and Foramen Spinosum

The embryology of the MMA relates to the hyoid (HA) and stapedial artery (SA) along

Conclusion

Recognition of the rare anomalous origin of MMA has practical value in determining the feasibility of embolization for vascular intracranial diseases including SDH. A thorough diagnostic angiogram is a prerequisite to safe neuroendovascular therapy. Embryologic-angiographic correlation provides a more solid academic basis for clinical decision making.

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There are more references available in the full text version of this article.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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