Anatomy of the Middle Meningeal Artery: Implications for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma

Abstract

Chronic subdural hematoma (cSDH) is among the most common neurosurgical conditions, particularly affecting older adults and patients receiving anticoagulation. While burr-hole evacuation has long been the standard therapy, recurrence rates and associated morbidity remain significant. Middle meningeal artery (MMA) embolization has recently emerged as a promising alternative or adjunctive treatment, offering durable hematoma control with reduced recurrence. To understand the rationale and safety of this endovascular approach, detailed knowledge of MMA anatomy, embryology, and variations is essential. This review synthesizes current understanding of the MMA from gross and microvascular perspectives, integrating embryological origins, common and rare anatomical variants, and dural angioarchitecture, with emphasis on how these factors inform embolization strategies for cSDH. By bridging historical anatomical insights with contemporary angiographic and clinical evidence, we aim to provide a comprehensive resource for clinicians and researchers involved in neuroendovascular therapy.