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The Study of Anatomy and Radiology of Middle Meningeal Arteries

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The Study of Anatomy and Radiology of Middle Meningeal Arteries THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI, TAMILNADU. THE STUDY OF ANATOMY AND RADIOLOGY OF MIDDLE MENINGEAL ARTERIES, VARIATIONS AND ITS CLINICAL IMPLICATIONS Dissertation submitted for M.Ch., (Neurosurgery) February – 2006 DEPARTMENT OF NEUROLOGY & NEUROSURGERY MADURAI MEDICAL COLLEGE MADURAI. CERTIFICATE This is to certify that this dissertation titled “The Study of Anatomy and Radiology of Middle Meningeal Arteries, Variations and its Clinical Implications” is a bonafide record of work done by Dr. K.S. Thirumurthy, Postgraduate student in M.Ch., Neurosurgery, Madurai Medical College, Madurai. Prof. Dr. V. INBASEKARAN, MCh., (Neuro) Head of the Department Dept. of Neurology & Neurosurgery Madurai Medical College and Government Rajaji Hospital, Madurai ACKNOWLEDGEMENT I take this opportunity to thank and honour a host of well-intended individuals who helped me in completion of this voluminous and arduous task. At the very outset I express my sincere gratitude to Dr.V.Inbasekaran, Professor and Head, Department of Neurology and Neurosurgery, Government Rajaji Hospital, Madurai, for his great kindness, inspiration and valuable suggestion throughout the period of my dissertation. I am extremely grateful to Dr.S.Manoharan and Dr.V.G.Ramesh for their academic assistance and consistent encouragement. I am indebted to the sincere compliments and enthusiasm rendered by Dr.D.Kailai Rajan, Dr.M.JeyaBalachandran, Dr.N.Asok Kumar, Dr.N.Muthukumar, Dr.C.Balasubramaniam, Dr. P. Parthasarathy and Dr. C. Balamurugan of the Department of Neurosurgery. My immense thanks are due to Dr.M.L.Prakash, Professor and Head, Department of Radiology for kindly permitting me to use their resources. I hereby record my sincere gratitude to all the staff of the department of Radiology with special mention to Dr.M.Selvarani (Tutor) and Mr. O.Chandran (Senior Technician). I earnestly thank Dr.T.Hariharan, Director and Professor, Institute of Anatomy, Madurai Medical College for his kindness in allowing me to use the cadavers and skulls available in their department. I acknowledge the efforts of Dr.V.Rajaram, Dr.N.B.Thanmaran and all other staff members of the Department of Anatomy. My sincere thanks to Dr. K. Meiyazhagan, Professor and Head, Department of Forensic Medicine for giving permission to use the corpse subjected for postmortem for study purpose and Dr. P. Raghavaganesan and the technicians of Forensic Medicine department, for their kind support during the study. I hereby thank the Dean of Madurai Medical College, for allowing me to use the college and hospital facilities during my study. I thank my colleagues, family, friends and well-wishers for their unequivocal support they gave me during this process. I thank Mr. S. Subburaj, Sri Balaji Computers for his efficient work in compiling and printing my thesis. My sincere thanks to the volunteers, who helped in the radiological study. My heartfelt respect to the souls who donated their corpse for the anatomical study. I owe my prayers to The Lord, who gave me the inner strength to complete this work. TABLE OF CONTENTS Sl. No. Titles Page 1. Introduction 1 2. Aims and Objectives 3 3. Review of Literature 4 4. Materials and Methods 26 5. Results 42 6. Discussion 45 7. Limitations of our study 50 8. Conclusion 51 Bibliography Master chart 1 INTRODUCTION The middle meningeal artery (MMA) is the largest of several meningeal arteries. It is also by far the most important branch of the maxillary artery. It is a common vessel encountered by neurosurgeons in their practice. There are considerable variations in the intracranial course and branching pattern of middle meningeal artery. Neurosurgeons need to know the variations in these vessels to understand varied clinical manifestations they present with and to avoid catastrophe during surgical or endovascular interventions. Clinical importance of middle meningeal artery: 1. Injury to middle meningeal artery is the commonest cause of extra dural hematoma after injury to the skull, which might be associated with skull fracture in 65 to 90% of the cases. In children, extradural hematoma occurs due to injury to posterior branch of middle meningeal artery. 2. There are variations in the source of origin course and branching pattern of the middle meningeal artery which are of clinical significance in fractures of squamous and petrous temporal bones, in surgical interventions of skull base tumors and in endovascular 2 interventions in cases of intracranial neoplasms especially meningiomas and in dural arterio venous malformations. Description of the course and relations of the middle meningeal artery to the endocranial surface of the bones of the cranial vault available in the text are scanty. There are studies in the European, Japanese and American population on the middle meningeal artery course and its variation in branching pattern. Indian studies are few. This study is made as an attempt to understand the variations in the endocranial course of middle meningeal arteries and radiology of middle meningeal arteries in the population of this region and highlight the clinical implication due to such variations. 3 AIMS AND OBJECTIVES AIMS 1. To study the course and relations of middle meningeal artery and variations of its branching pattern within the cranium. 2. To study the radiology of middle meningeal artery in normal individuals 3. An attempt to understand the significance of variations in course and branching pattern of middle meningeal artery. OBJECTIVES 1. To emphasize the variations in endocranial course of middle meningeal artery and its branching pattern. 2. To enable the neurologists and neurosurgeons to understand and correlate the varied clinical manifestations which occur due to such variations. 3. To stress the importance of such variations which might be encountered during surgical and endovascular interventions in order to avoid major catastrophe. 4 REVIEW OF LITERATURE The middle meningeal artery (MMA) is the largest of all the meningeal arteries supplying the dura of the cranium. GROSS ANATOMY Middle meningeal artery arises from the first part of maxillary artery and ascends between the sphenomandibular ligament and lateral pterygoid. It passes between the roots of auriculo-temporal nerve and lies lateral to tensor- veli- palatini before entering the cranial cavity through the foramen spinosum. It then runs in an anterolateral groove on the squamous part of the temporal bone dividing into frontal and parietal branches. The frontal (anterior) branch, the larger one, crosses the greater wing of sphenoid and reaches a groove or canal in the parietal’s sphenoidal angle and divides into branches between the dura and the cranium, some ascending to the vertex and others to the occipital region. One ascending branch grooves the parietal bone about 1.5 cm behind the coronal suture, corresponding approximately to the precentral sulcus. The parietal (posterior) branch curves back on the squamous temporal bone reaching the lower border of the parietal bone anterior to its mastoid angle and dividing to supply the posterior parts of the dura matter and cranium. These branches anastomose with their fellows and with anterior and posterior meningeal arteries. 5 In the cranial cavity the artery has the following branches 1. Numerous ganglionic branches which supply the trigeminal ganglion and roots 2. A petrosal branch enters the hiatus for the greater petrosal nerve and supplies the facial nerve, ganglion and tympanic cavity anastomosing with the stylomastoid artery. 3. A superior tympanic artery runs in the canal for tensor tympani supplying both the muscle and the canal’s lining membrane. 4. Temporal branches traverse minute foramina in the greater wing of sphenoid and anastomose with deep temporal arteries. 5. An anastomotic branch enters the orbit laterally in the superior orbital fissure anastomosing with the recurrent branch of lacrimal artery; enlargement of this anastomosis explains an occasional origin of the lacrimal artery from the middle meningeal artery. 6. Apart from this and supply to the dura matter the middle meningeal artery is predominantly periosteal, supplying bone and red bone marrow. 7. Accessory meningeal artery may arise from middle meningeal artery in 50% of cases. 6 Surface anatomy The middle meningeal artery enters the skull medial to the zygoma’s mid point dividing two centimeters above this. From here the frontal branch runs first up and forwards to the pterion and then up and back towards the point midway between the inion and nasion. The parietal branch runs up and back towards the lambda. Guiffraida-Ruggeri (1913) has devised a classification of the branching pattern using the origin of the middle branch of as the criterion, which is not described in classical description of middle meningeal artery branches in the text books. Adachi simplified this in 1928, which is being followed nowadays. Embryology During embryonic development, the first and second aortic arch arteries begin to regress and a transient ventral pharyngeal artery grows from the aortic sac and terminates by dividing into mandibular and maxillary branches. Later the stapedial artery develops from the dorsal stem of the second arch artery and passes through the condensed mesenchymal site of the future ring of the stapes to anastomose with the cranial end of the ventral pharyngeal artery thereby annexing its terminal distribution. The fully developed stapedial artery possesses three branches, mandibular, maxillary and supraorbital, which follow the divisions of the trigeminal nerve. The mandibular and maxillary 7 branches arise from a common stem. When the external carotid artery emerges from the base of third arch it incorporates the stem of the ventral pharyngeal artery and its maxillary branch. It communicates with the common trunk of the origin of the maxillary and mandibular branches of the stapedial artery and annexes these vessels. The proximal part of the common trunk persists as the root of the middle meningeal artery. More distally the middle meningeal artery is derived from the proximal part of the supraorbital artery. The maxillary branch becomes the infraorbital artery and the mandibular branch forms the inferior alveolar artery.
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