The many faces of middle meningeal artery: A comprehensive review of anomalous variations and endovascular implications.

BackgroundMiddle meningeal artery (MMA) embolization is an increasingly common procedure involved in the treatment of various vascular and neoplastic diseases. Understanding its anatomical nuances and clinical implications is fundamental in enhancing the safety of preoperative embolization.MethodsA systematic review following PRISMA guidelines was conducted to consolidate literature on the MMA anomalous variations. PubMed, Scopus, and Web of Science were systematically searched using our predefined criteria until 2025. Inclusion encompassed studies focusing on the clinical perspectives of MMA's anomalous anatomy and endovascular implications.ResultsTwelve articles met inclusion criteria, exploring the clinical significance of the MMA's anatomical variations in various clinical situations. We identified 11 case reports, and we also reported the clinical significance of the cases identified among different case series for the treatment of CSDH and other involved pathologies. Anomalous variations of the MMA involving either its origin, branching or connections were detected clinically in about 43 patients in the literature. We identified the basilar artery as an origin of the MMA in 9 case reports. The ophthalmic origin of the MMA was reported in about 12 patients, while an accessory meningeal artery arising from an ophthalmic artery was only reported in two cases.ConclusionProperly identifying the anomalous variants of the MMA is considerably valuable in preoperative planning and decision-making for the endovascular management of various pathologies involving the dura. To choose an appropriate tool and method of endovascular intervention, understanding the anatomical features and variability of the MMA is crucial.