REVIEW ARTICLE Middle Meningeal Artery: Anatomy and Variations S. Bonasia, S. Smajda, G. Ciccio, and T. Robert ABSTRACT SUMMARY: The middle meningeal artery is the major human dural artery. Its origin and course can vary a great deal in relation, not only with the embryologic development of the hyostapedial system, but also because of the relationship of this system with the ICA, ophthalmic artery, trigeminal artery, and inferolateral trunk. After summarizing these systems in the first part our review, our purpose is to describe, in this second part, the anatomy, the possible origins, and courses of the middle meningeal artery. This review is enriched by the correlation of each variant to the related embryologic explanation as well as by some clinical cases shown in the figures. We discuss, in conclusion, some clinical conditions that require detailed knowledge of possible variants of the middle meningeal artery. ABBREVIATIONS: IMA ¼ internal maxillary artery; MMA ¼ middle meningeal artery; OA ¼ ophthalmic artery; SA ¼ stapedial artery he middle meningeal artery (MMA) is one of the largest surprisingly, from the basilar artery. Possible origins of the MMA Tbranches of the external carotid artery and the most important are listed in Table 1, with their respective embryologic explana- dural artery because it supplies more than two-thirds of the cranial tion. The detailed description of the MMA embryologic develop- dura.1 However, the most interesting aspects of this artery are not ment was analyzed in part 1 of our article. its size or its clinical importance but its embryologic development and its numerous anatomic variations. An understanding of the IMA Origin. The classic origin of the MMA is usually described anatomy and variants of the MMA provides a good knowledge and on the first segment of the IMA into the infratemporal fossa, just understanding of the hyostapedial system and of the vascular anat- behind the condylar process of the mandible.1,2 The MMA is the omy of the middle ear. The aim of this article is to summarize, largest and usually the first ascending branch of the IMA,2 but it through a narrative review based on the literature and clinical could also have a common trunk with the accessory meningeal examples, the possible anatomic variations of the MMA. Each vari- artery, depending on the position of the IMA course with regard ant will be related to its embryologic explication, which we treated to the external pterygoid muscle.3 When the IMA passes superfi- in detail in part 1 of this article. The knowledge of these variants is cially to the muscle, the MMA and accessory meningeal artery important especially for neuroradiologists to treat dural pathologies have a common origin from the IMA, and the inferior dental and and also for surgeons who approach the middle ear pathologies. posterior deep temporal arteries have a separate origin. On the contrary, when the IMA passes deep to the external pterygoid muscle, the MMA, and the accessory meningeal artery have dis- Origin of the Artery tinct origins from the IMA, and the inferior dental and the poste- In almost all cases, the MMA arises from the internal maxillary rior deep temporal arteries share a common trunk.2 artery (IMA), but it could also originate from the ICA or, more Low4 described an interesting cadaveric case of distal (third Received April 17, 2020; accepted after revision May 20. segment) IMA origin of the MMA. In his study, he inspected From the Department of Neurosurgery (S.B., T.R.), Neurocenter of the Southern the osseous grooves of the skull and noted that, associated with Switzerland, Lugano, Switzerland; Department of Interventional Neuroradiology (S.S., G.C.), Rothschild Foundation Hospital, Paris, France; and University of the absence of the foramen spinosum, the osseous grooves of the Southern Switzerland (T.R.), Lugano, Switzerland. MMA converge to the superior orbital fissure.4 He concluded Please address correspondence to Thomas Robert, MD, Department of that the MMA takes its origin in the pterygoid fossa from the dis- Neurosurgery, Regional Hospital of Lugano, Neurocenter of the Southern Switzerland, Via Tesserete 46, CH-6903 Lugano, Switzerland; e-mail: tal IMA and passes through the inferior and superior orbital fis- [email protected] sures.4 Probably, in his description, he misinterpreted an Indicates open access to non-subscribers at www.ajnr.org ophthalmic artery (OA) origin of the MMA, not already known http://dx.doi.org/10.3174/ajnr.A6739 at its publication.3 AJNR Am J Neuroradiol 41:1777–85 Oct 2020 www.ajnr.org 1777 Table 1: Different origin of the MMA with modifications associated and embryologic explanation Variations in the Origin of the MMA Embryologic Implications Embryo Type Associated Changes Embryologic Explanation Size (mm) IMA origin Normal anatomy Normal embryology Basilar artery origin Absence foramen spinosum Anastomosis between SA and trigeminal artery; 12 anastomosis between SA and lateral pontine artery Cavernous ICA origin Absence foramen spinosum Anastomosis between inferolateral trunk and SA 16 Partial persistent SA Absence foramen spinosum; enlargement Regression of the proximal part of the 24 of the facial canal maxillomandibular branch; persistence of the intratympanic segment of the SA Complete persistent SA Enlargement of the facial canal Lack of annexation of the maxillomandibular 24 branch by the ventral pharyngeal artery; persistence of the intratympanic segment of the SA Pseudopetrous ICA origin Absence foramen spinosum; enlargement Agenesis of the first and second segments of the 4–5; 24 of the facial canal; absence of the ICA; intratympanic anastomosis between exocranial opening of the carotid canal inferior tympanic and caroticotympanic arteries; persistence of the intratympanic segment of the SA Cervical ICA origin Absence foramen spinosum; enlargement Intratympanic anastomosis between inferior and 16; 24 of the facial canal superior tympanic arteries; regression of the proximal part of the maxillomandibular branch; persistence of the intratympanic segment of the SA Occipital artery origin Absence foramen spinosum; enlargement No clear explanation of the facial canal Distal petrous ICA origin Absence foramen spinosum Lack of annexation of the mandibular artery (first 9 aortic arch) by the SA (second aortic arch) Basilar Artery Origin. Altmann5 was the first investigator to al10 described a particular case in which the MMA arose directly describe a case of basilar artery origin of the MMA in his monu- from the PICA and not from the basilar artery. No embryologic ex- mental article about anomalies of the carotid system but failed to planation was found to explain such an origin. give clear embryologic explanation of the anatomic variation. Surprisingly, he described the origin of the artery between the OA Origin. The MMA could also originate from the OA instead “ AICA and PICA, and its course as accompanying the acoustic- of the IMA. The incidence of this vascular variation is estimated ” facial nerve, passing through the internal acoustic canal to reach to be 0.5% by Dilenge and Ascherl,15 based on a large angio- the superior branch of the stapedial artery (SA). After this initial graphic series. Few cases of MMA that arose from the OA are description, ,10 cases of basilar artery origin of the MMA were 7,16-24 6-12 described in the literature. The first case was presented by successively published. Usually, the MMA originates from the Curnow25 and, in the same period, Meyer26 also cited 4 cadaveric distal third of the basilar artery between the superior cerebellar cases originally described by Zuckerkandl in 1876,27 during a artery and the AICA. It courses anteriorly along the trigeminal congress presentation. This vascular anomaly is considered as the nerve to reach the gasserian region, where it anastomoses with 7 consequence of 2 different embryologic processes. The first is the petrosal branch of the MMA. Usually, only the posterior the failure of the supraorbital branch (SA) to regress. The second (parieto-occipital) branch of the MMA arises from the basilar ar- is the absence of anastomosis between the maxillomandibular tery and the anterior (frontal) branch keeps its normal origin 28 branch of the SA and the IMA. Consequently, the MMA origins from the IMA6,9-11,13; however, in a few cases,6,8,12 the complete from the OA passing through the lateral part of the superior or- territory of the MMA had a basilar artery origin. bital fissure and the foramen spinosum are usually absent. Two distinct embryologic explanations are postulated by inves- Maiuri et al29 proposed 3 different types of this vascular varia- 6 tigators to explain this anatomic variation. Seeger and Hemmer tion, as highlighted in Table 2. The first type is the complete 3,7 and Lasjaunias et al explained it by an anastomosis in the gasser- MMA territory taken over by the OA through the superficial recur- ian region between the basilar remnant of the trigeminal artery rent OA. The second type is only the anterior branch of the MMA and the persistent SA. Consequently, after regression of the proxi- with an OA origin; the posterior branch of the MMA keeps its ori- mal stem of the SA at the level of the stapes, the MMA takes its ori- gin from the IMA. The third type is not really an OA origin of the gin from the basilar artery. Other investigators postulated that an MMA but an anastomosis between the OA and the accessory me- enlarged lateral pontine artery develops during the embryologic ningeal artery (through the deep recurrent OA), and, consequently, life and anastomoses with the SA.8,9,14 ArarecaseofMMAorigin the anterior meningeal territory is supplied by both the MMA and from an enlarged pontine artery is presented in Fig 1. Kuruvilla et the OA, without any communication. Two cases of complete and 1778 Bonasia Oct 2020 www.ajnr.org SA; consequently, the proximal stem of the MMA regressed (or was not formed) and the foramen spinosum was absent.