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

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.