Aneurysms of the meningeal arteries: systematic review and illustrative case series.

Meningeal artery aneurysms are a rare but clinically significant pathology, distinct from cerebral aneurysms and classified as traumatic (trAA) or non-traumatic (non-trAA). Their natural history, optimal diagnosis, and management remain poorly defined. A PRISMA-guided systematic review was conducted (PubMed/MEDLINE, Scopus, Web of Science) up to July 2025. We analyzed all reported cases of meningeal artery aneurysms to develop a novel pathophysiology-based classification and evaluate treatment outcomes. A supplementary institutional series of nine combat-related trAA cases is presented. Among 144 analyzed cases (44 non-trAA, 100 trAA), a new classification system was proposed. Non-trAA were categorized as sporadic (32%), hemodynamic/flow-related (61%), or genetic / dysplastic (7%). Hemodynamic subtypes were associated with hypervascular tumors, AV-shunts, atherosclerotic stenosis and developmental abnormalities. Rupture rates were high in sporadic (79%) and hemodynamic (52%) subtypes, with subdural and intracerebral hemorrhages predominating. Delayed rupture occurred in 26% of trAA cases (median latency 14 days). Endovascular techniques becoming the primary treatment implemented in 72% of recent cases (after 2002). Outcomes were significantly worse for ruptured aneurysms (35% poor outcomes) versus non-ruptured (6%). Though uncommon, aneurysms of the meningeal arteries - whether spontaneous, disease-related, or traumatic - remain a frequently overlooked threat in neurosurgical practice. Clinical recognition of meningeal aneurysm risk factors enables targeted diagnostic evaluation and timely intervention, thereby facilitating minimally invasive treatment approaches that optimize patient outcomes.