Anomalous Origin Of The Middle Meningeal ArteryA Review

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J Anat. Soc. India 50(2) 179-183 (2001)

Anomalous Origin Of The Middle Meningeal Artery—A Review.
Manjunath, K.Y.

Department of Anatomy, St. John’s Medical College, Bangalore - 560 034

       Abstract. Middle meningeal artery (MMA) is the largest and most important of the arteries supplying the meninges. It is usually a
branch of the first part of maxillary artery. However other sources of its origin have been described in literature viz : third part of maxillary
artery, ophthalmic artery, persistent stapedial artery, internal carotid artery, basilar artery and rarely ascending pharyngeal artery. These
anomalous origins of MzMA are of clinical significance in cases of fractures of the squamous and petrous temporal bone, and in surgical
interventions involving Vidian nerve or the ligation of the middle meningeal artery. Literature on the incidence of the variations of the origin of
the MMA and their embryological basis is reviewed here.

       Key words :      Dural vascularization, Arterial variations, skull, Head injuries.

Introduction :                                                                     middle meningeal artery (OMMA). Earliest
       The middle meningeal artery (MMA) is the                                    cases of the OMMA were reported by Curnow
largest of the several meningeal arteries; it is also                              (1874) and Zuckerkandl (1976) (cited by Royle
by far the most important branch of the maxillary                                  and Motson- 1973; McLennan, Rosenbaum
artery as it is a frequent source of haemorrhage                                   and Haughton-1974)
after injury to the skull. The MMA is usually a branch                      4.     Rarely MMA may arise as a branch of the
of the first part of the maxillary artery. Other sources                           persistent stapedial artery (PSA). The PSA is
of its origin and course have been described in the                                usually a branch of the intrapetrous portion of
literature. These variations are of clinical                                       the internal carotid artery, enters the tympanic
significance in fractures of the squamous and                                      cavity through its floor and passes through the
petrous parts of the temporal bones and surgical                                   obturator foramen of the stapes. For a short
interventions involving the nerve of the pterygoid                                 distance it is enclosed in a bony canal over the
canal and maxillary artery (Klisovic, Sikic and                                    promontary and enters the facial canal, and
Krmpotic-Nemanic 1993).                                                            emerges in to the middle cranial fossa under
                                                                                   the dura and gives off the middle meningeal
Sources of anomalous origin of the MMA :                                           branch (Altman 1947). The MMA of stapedial
1.     In the absence of foramen spinosum the MMA                                  origin is called the stapedial middle meningeal
       may enter the middle cranial fossa through the                              artery (SMMA). The first case of PSA was
       foramen ovale along with the mandibular                                     described by Hyrtl in 1836 (McLennan et al
       nerve (Bartlett 1902 ; Chandler and Derezinski                              1974).
       1935).                                                               5.     The MMA can also originate from prepetrous
2.     The MMA may arise as a branch of the third                                  and suprasellar portion (extradural portion of
       part of the maxillary artery (sphenomaxillary                               the carotid siphon) of the internal carotid
       portion) and enter, the middle cranial fossa                                artery. (Newton and Potts 1974, Dilenge and
       through the lateral end of the superior orbital                             Ascherl 1980).
       fissure (SOF) (Toida 1934; Low 1946).                                6.     The MMA may also arise as a branch of the
3.     The MMA may partially (i.e. only the anterior                               intra cavernous portion (juxtasellar) of the
       branch) or completely arise from the                                        internal carotid artery (Newton and Potts
       ophthalmic artery. Under such circumstances it                              1974, Tran-Dinh and Jayasinghe 1983).
       passes through the lateral end of the SOF or a                       7.     Some authors have reported anomalous origin
       foramen in the greater wing of the sphenoid                                 of MMA from the basilar artery (Seeger and
       (foramen meningo-orbitale). The MMA of                                      Hemmer 1976 ; Waga, Okada, Yamamoto
       ophthalmic origin is known as the ophthalmic                                1978; Katz Wisoff, Zimmerman 1981).
J. Anat. Soc. India 50(2) 179-183 (2001)
180                                                                                        Middle Meningeal Artery

8.    A rarest instance of MMA arising from the           Origin of the MMA from the pertrous segment of the
      ascendig pharyngeal artery also has been            internal carotid artery :
      reported (Moret, Lasjaunias, Vignaud, Doyon                The basis of this anomaly is persistence
      1978).                                              (failure of involution) of the embryonic stapedial
    With the advent of the angiographic technique         artery. This artery has been the subject of numerous
more and more cases of anomalous origin of the            anatomic dissections (Hyrtl 1936 ; Alexander 1849;
MMA are being reported in the literature.                 Brock 1922 cited by Marion, Hinojosa, Khan 1985;
                                                          Davies 1967), and has been reported to be observed
Embryological basis :                                     by chance, in three occasions during middle ear
                                                          surgery (Baron 1963; House and Patterson 1964).
      The available embryologic literature on the
                                                          While naturally present in adult rodents and some
development of the cranial arteries suggests a
                                                          bats, PSA in man is a rarely reported anomaly,
fundamental relationship between the development
                                                          Rarity of this anomaly can be appreciated by the
of the ophthalmic and middle meningeal arteries,
                                                          fact that House and Patterson (1964) encountered
and the embryonic stapedial artery (Dilenge and           this anomaly only twice during 8,000 procedures on
Ascherl 1980). Knowledge concerning the early             the middle ear, whereas, Steffen (1968) noticed only
development of the stapedial artery is obscure, but       two cases during 10,000 middle ear operations. First
however some observations by Tandler (1902),              reported by Hyrtl in 1836, only around thirty cases of
Evans (1912) and Padget (1948) [summarised from           this anomaly have been documented in the past 165
Dilenge and Ascherl 1980] permits some                    years of its history (see Table 1). Guinto, Garrabrant
assumptions (see fig.1): The stapedial artery is          and Radcliffe (1972), were the first to report the
formed by the union of the remnants of the first          angiographic features of PSA. The course of the
branchial arch with the hyoid artery. After having        PSA has been well documented by Altman (1947).
penetrated the ring of the stapes it divides into two     When present, it can pose a technical problem
definitive divisions :                                    during stapes surgery (Guinto et al 1972). A large
                                                          PSA has been frequently reported in association
1.    A maxillofacial division consisting       of   an
                                                          with other anomalies : anencephaly and Paget’s
      infraorbital and a mandibular branch.
                                                          disease (Altman          1947); multiple congenital
2.    A supra orbital division consisting of branches     anomalies (Keleman 1958; Sando, Baker and Black
      destined to supply the orbit and the intracranial   1972 cited by Marion et al 1985); thalidomide child
      segment of the MMA. The branches of the             (Maran 1965 cited by Marion et al 1985); first arch
      maxillofacial division are assimilated by the       anomaly (Pascual-Castroveijo 1983).
      developing external carotid artery and forms
      the maxillary artery (including the extracranial    Ophthalmic origin of the MMA (OMMA) :
      part of the MMA). At this stage the proximal            Two separate processes are involved in this
      part of the stapedial artery involutes, and its     anomaly :
      remnants become the tympanic branches of            1.   Failure of the proximal intra orbital and retro
      the MMA.                                                 orbital stapedial branches to involute, so that
      The supra orbital division of the stapedial              the intracranial segment of the MMA remains
artery forms in addition to the extraocular intra              connected with the intraorbital stapedial
orbital arteries, the intracranial segment of the              branches.
MMA. After the intraorbital branches of the stapedial     2.   Defective involution of the maxillofacial
artery are assimilated by the ophthalmic artery its            division of the stapedial artery so that the
proximal intra and retro orbital branches involute             extracranial segment of the MMA is never
and become resorbed by the intracranial segment of             formed. As a result, no connection forms
the MMA.                                                       between the maxillary artery and the

                                                                             J. Anat. Soc. India 50(2) 179-183 (2001)
Manjunath, K.Y.                                                                                                181

      intracranial segment of the MMA (Dilenge and        ophthalmic artery has also been described (Newton
      Ascherl 1980).                                      and Potts 1974).
       The ophthalmic origin of the MMA is a                    A large meningeal branch originating from the
relatively frequent anomaly. Dilenge and Ascherl          lacrimal artery has been observed in angiograms in
(1980) found 17 cases of MMA arising from the             cases of pterional meningiomas. Such branches are
ophthalmic artery among 3.500 cerebral angiograms         pathological and serve only as a feeder vessel to
examined by them (0.5%). Earliest cases of MMA            the tumour in that region (Galligioni, Pallone,
arising from the ophthalmic artery have been              Bernardi, Iraci 1967). Origin of the MMA from
described by Curnow (1874) and Zukerkandl (1876).         extradural part of the carotid artery is quite rare (see
Royle and Motson (1973) have described a case of          table 1). A possible embryologic mechanism relates
bilateral origin of the MMA from the ophthalmic in        to an aberrant origin of the hyoid artery from the
an adult skull of Asiatic origin, which is probably the   internal carotid artery, so that its union with
first photographic record of this anomaly. Gabriele       remnants of the first branchial arch to form the
and Bell (1967) consider their report of three cases      stapedial artery either does not occur or occurs with
of ophthalmic origin of the MMA as the first              out any relation to the level of the stapes (Dilenge
arteriographic demonstration of this anomaly.             and Ascherl 1980).
      Instances of partial origin of MMA (only the              Only a few cases of the MMA arising from the
anterior branch) have been reported previously :          basilar artery have been reported (Seeger and
Toida (1934) in his study of 192 Chinese skulls           Hemmer 1976; Waga et al 1978; Katz et al 1981).
found five instances of anterior branch, and only         The embryology of this anomaly has not been
one instance of the complete stem of the MMA              described and is only speculative. Waga et al (1978)
originating from the orbit (Low 1946). Chandler and       feel that this anomaly is due to an anastomosis
Derezinski (1935) in their study of 1200 sides of the     between the trigeminal artery and the PSA.
skull found only one instance of the anterior branch
of the MMA arising from the orbit. Klisovic et al         Relationship of the foramen spinosum to the
(1993) found 1% incidence of the cases of partial         anomalous origin of the MMA :
origin of the MMA from the ophthalmic artery in their           Absence of the foramen spinosum often
study. Embryological basis of this partial origin of      accompanies aplasia of the conventional MMA.
the MMA from the ophthalmic is, that sometimes the        Substitution of the MMA by the OMMA or PSA
extracranial segment of the MMA forms normally            would also be expected to result in the absence of
and unites with the intracranial segment, with only       this foramen. A small foramen spinosum suggests
partial involution of the retro orbital stapedial         hypoplasia of the conventional MMA; under such
branches so that some connection with the MMA is          circumstances, a second source of the meningeal
maintained (Dilenge and Ascheri 1980). Under such         blood supply should be sought (McLennan et al
a circumstance the anterior branch originates from        1974). McLennan et al (1974) in their examination of
the ophthalmic and the posterior from the maxillary       108 dried skulls found only one skull with bilateral
artery. According to Falk and Nicholls (1992), the        and another with unilateral absence of foramen
anterior branch of the MMA of humans is                   spinosum. Low (1946), Royle and Motson (1973)
homologous with the meningeal lacrimal artery of          have also noticed bilateral absence of the foramen
rhesus monkeys. All three of the homologues,derive        spinosum in their report of the anomalous origin of
(developmentally) from the ophthalmic artery, and         the MMA, from the orbit. The evolution of selective
supply the same region of the skull and duramater.        and even subselective cerebral angiography,
The difference is that the homologous artery is           coupled with continued refinement in angiographic
usually distinct from the MMA in monkeys and apes,        imaging apparatus and substraction technique, has
but has become incorporated as the anterior branch        permitted remarkable progress in ability to resolve
of the MMA in humans. Incidence of the posterior          vascular anatomy (Dilenge and Asherl 1980).
branch of the MMA alone arising from the                  Selective catheterisation of branches of the
J. Anat. Soc. India 50(2) 179-183 (2001)
182                                                                                               Middle Meningeal Artery

common carotid artery has facilitated the                      Nos 2, 3, 4, 7, 9, 10, 14 are cited from
angiographic demonstration of anomalous origin of              Marion et al. - No. 21
the MMA (Mclennan et al 1974). Around fifty cases              (b)     Intra cavernous part (Juxtasellar) (1)
of the MMA of ophthalmic origin have been reported                     Newton and Potts (1974-c-1) (2) Tran-
so far (see Table-I).                                                  Dinh & Jayasinghe (1983-c-1)
                       Table 1                                 (c)     Prepetrous & Suprasellar part (1) Newton
 Case Reports of The Anomalous Origin of The                           and Potts (1974-c-1) (2) Dilenge and
          Middle Meningeal Arterty                                     Ascherl (1980-c-1)
Source of the anomalous MMA                              IV.   Basilar artery : (1) Altman (1974-b-1) (2)
Authors (Year; material observed* no. of cases)                Seeger and Hemmer (1976-c-3) (3) Waga,
                                                               Okada, Yamamoto      (1978-c-1) (4) Katz.
I.     3rd part of Maxillary artery : (1) Low (1946-a-
                                                               Wisoff, Zimmerman (1981-b, c-1)
                                                         V.    Ascending pharyngeal artery : (1) Moret,
II.    Ophthalmic artery : (1) Curnow (1874-b-1) (2)           Lasjaunias, Vignaud, Doyon (1978-c-1)
       Zuckerkandl (1876-b-0) (3) Quain (1892-**)
       (4) Whitnall (1932-**) (5) Toida (1934-a-5 ant.
                                                               *Material observed-(a) dry skulls, (b) cadaver/
       branch only; I-complete stem) (6)     Chandler
                                                         postmortem dissection/clinical case (c) angiography.
       and Derezinski (1935 -a-ant. branch only-1) (7)
                                                         **indicates material observed/number of cases not
       Bernasconi (1965-**) (8) Gabriele and Bell
       (1967-c-3) (9) Royle and Motson (1973-a-1)
       (10)   Takahashi,     Tamakawa,     Kishikawa,          Unlike the MMA of stapedial origin there have
       Kowada (1973-c-*0) McLennan, Rosenbaum            been no reports of a case of MMA of ophthalmic
                                                         origin presenting with clinical symptoms. Anomalous
       and Haughton (1974-a-2; c-5) (12) Dilenge and
                                                         origin of the MMA from the third part of the
       Ascherl (1980 -c-17) (13) Nakagawa, Tanabe,
                                                         maxillary artery or the ophthalmic is of surgical
       Sato (1982-c-2)
                                                         interest beause it would be difficult to ligate its main
       Nos. 1,2 cited from No. 9; Nos. 3. 4. 7 cited     trunk, Since it will not be found in its normal place in
       from No. 8; No-5 from No. 6                       comparison to the conventional MMA located in the
III.   Internal carotid artery : (a) Intrapetrous part   floor of the middle cranial fossa, where it would be
       (stapedial art.) (1) Hyrtl (1936-b-*) (2)         within easy access (Low 1946, Klisovic et al 1993).
       Zuckerkandl (1873-b-*)/3) Alexander (1899-b-*
       (4) Brock (1922-b-) (5) Altman (1947; 57-b-2)     References :
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       Ascherl (1980-c-3) (19) Morano, Horton,            5.   Chandler, S. B. and Derezinski, C. F. (1935) : The variations
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                                                                                    J. Anat. Soc. India 50(2) 179-183 (2001)
Manjunath, K.Y.                                                                                                                       183

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                                                                        This Article Can be Downloaded / Printed Free from
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J. Anat. Soc. India 50(2) 179-183 (2001)
Opp. 180                                                                                                   Middle Meningeal Artery

      Fig I : (1-4) 1- shows the stapedial artery (sta) arising from the internal carotid artery and dividing into, supra orbital (SO)
and maxillofacial (MF) divisions. 20mm stage embryo. 2-maxillofacial and middle meningeal arteries (MMA) have been
assimilated into external carotid artery (ECA) to form the maxillary artery (MAX); supra orbital division (SD) has united with the
ophthalmic artery (OA)- following the involution of the stapedial artery. 3- The middle meningeal artery (mma) being given off by
the persistent stapedial artery (sta). 4- The intracranial part of the MMA has become annexed to the ophthalmic artery giving rise
of ophthalmic middle menningeal. [based on the descriptions from, Davies 1967; Dilenge and Ascherl-1980; Marion. Hinojosa,