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StatPearls . Treasure Island also (FL): StatPearls Publishing; 2021 Jan-.


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Neuroanatomy, Middle Meningeal Arteries

Adriana L. Natali; Vamsi Reddy; Jonathan T. Leo.

Author Information

Introduction

The middle meningeal artery is an essential artery that plays an important clinical duty. The middle meningeal artery (MMA) usually branches off the maxillary artery, which is an expansion of the exterior carotid artery. The artery will then take a trip with the foramen spinosum, which is posterolateral from the foramales ovale, to supply blood to the dura mater. The middle meningeal artery arises from a facility embryological origin, which provides rise to many kind of anatomic variations of the artery. Awareness of these anatomic variations becomes essential for surgeons to alleviate the threat of complications during surgical repair. 

The middle meningeal artery has a variety of clinical effects. Rupture of the artery, which a lot of typically occurs at the pterion, generally leads to an epidural hematoma. The resulting hematoma is defined as a “lens-shaped” mass on a computed tomogram (CT) scan. Damage to the middle meningeal artery may also result in an aneurysm or arteriovenous fistulas. Due to the middle meningeal artery"s attachment to the pain-sensitive dura mater, the artery additionally plays a duty in migraine headaches.


Structure and also Function

The middle meningeal artery most regularly branches off the maxillary artery and also courses into the middle cranial fossa using the foraguys spinoamount. The middle meningeal artery gives blood to the dura mater through and also with its branching arteries likewise provides the periosteum of the inner aspects of the cranial bones.<1> As the middle meningeal artery enters the dura mater, it follows a addressed course as it embeds into the groove of the inner skull confront.<2> Due to the middle meningeal artery"s close contact to the inner skull, trauma to the lateral skull may lead to a rupture. The after-effects of rupturing the middle meningeal artery will be better explained in the clinical definition area.


Embryology

The advance of the middle meningeal artery, similarly to other blood vessels, occurs using angiogenesis and receives guidance from vascular endothelial expansion factor (VEGF) and also other development determinants. Throughout advancement, a collection of aortic arcs arise, arranged from cranial to caudal. From these arcs, the 3rd arch provides climb to the stapedial artery. The stapedial artery arises from the inner carotid artery and is later on integrated by the exterior carotid artery. The stapedial artery will certainly then divide, giving climb to the middle meningeal artery. By the 10th week of breakthrough, the stapedial artery will certainly normally degeneprice. Due to the facility nature of middle meningeal artery breakthrough, many anatomic variations and also anastomoses might be seen.<3>


Physiologic Variants

While the middle meningeal artery mostly is derived as a branch from the maxillary artery and then passes via the foramen spinosum into the middle cranial fossa, rare anatomical variations have actually been observed. It is crucial to be mindful of the feasible variations of the middle meningeal artery, to minimize the risk of thromboembolism throughout the operative treatment of a lesion in the location. In cases wright here the foraguys spinoamount has been missing, the middle meningeal artery enters the cranial fossa via the foramen ovale alongside the mandibular nerve. The middle meningeal artery may additionally originate from the lateral element of the internal carotid artery. In this instance, it will certainly take a trip in the carotid canal, together with the internal carotid artery, and enter the skull via the foramales lacerum wbelow it will certainly then take a normal course and also divide into anterior and also posterior branches. The middle meningeal artery has actually likewise rarely originated from the posterior cerebellar artery, basilar artery, ascending pharyngeal artery, or ophthalmic artery.<1><4><5> Due to the potential for variation in the middle meningeal artery, imaging must be obtained prior to undergoing invasive therapy.


Surgical Considerations

Tears of the middle meningeal artery resulting in a far-reaching epidural hematoma are often treated surgically through overwhelming success in non-comatose patients.<6> Studies are currently assessing the efficacy of dealing with small epidural hematomas non-operatively, yet surgical treatment, particularly in the cases of large acute epidural hematoma, is still the primary therapy. Traumatic pseudoaneurysms are at high danger of additional rupture and have to be surgically regulated without delay.<7> True aneurysms of the middle meningeal artery are treated with open up surgical procedure and also endovascular embolization.<8> When treating any lesion or aneurysm of the middle meningeal artery surgically, surgeons need to be aware of the variations in the artery’s course and branching to alleviate the hazard of complications throughout the procedure.<1><4>


Clinical Significance

Epidural Hematoma

The meningeal vessels carefully adbelow to the interior element of the boney vault of the skull. As an outcome, injury to the boney vault of the skull can cause the rupture of the artery. Injury to the lateral facet of the skull, by means of trauma to the pterion, might lead to rupture of the vessel. Most typically (85%), this type of injury to the middle meningeal artery will bring about an epidural hematoma.<1> Symptomatic epidural hematoma classically presents through a loss of consciousness, adhered to by a lucid interval, and also finishing through quick deterioration in neurological status.<9> Small epidural hematomas without mass result may be treated conservatively,<7> however at an early stage surgical intervention is common in symptomatic patients.<9>

Arteriovenous Fistula

Arteriovenous fistulas (AVFs) are an additional clinical complication of the middle meningeal artery. Anatomically, the middle meningeal artery runs in addition to paired veins, and also a traumatic tear in the skull wall might cause a traumatic AVF.<1> The incidence of traumatic middle meningeal AVF is fairly high, however clinical complications are not checked out routinely. For this factor, it is thought that many kind of traumatic AVFs solve spontaneously. Cases of longstanding AVF, however, have actually predisposed patients to complications ranging from venous congestion to intracranial hemorrhage.<10> A middle meningeal AVF might happen without trauma, such as in the cases of craniotomy or endovascular injuries during interventional manipulation. Clinical symptoms are often checked out in iatrogenic AVFs, bring about intervention to be necessary.<1>

Aneurysm

Unfrequently, aneurysms of the middle meningeal artery might be checked out. Both true aneurysms and pseudoaneurysms may be oboffered in the middle meningeal artery, arising under different problems. Pseudoaneurysms are the majority of generally associated via trauma to the skull and also are responsible for the lucid interval prior to a delayed bleed.<7> A fracture in the tempdental area may cause a tear in the arterial wall. The tear is then blocked via a clot, leading to the formation of a false lumen. In comparison, true aneurysms are mostly linked with boosted hemodynamic tension or a pathological procedure affecting the middle meningeal artery.<2> Both forms of aneurysms are particularly prone to rupture, which regularly leads to an intracranial hemorrhage. Due to the danger of rupture, surgical rearea and endovascular embolization are the a lot of common treatment modalities. 

Migraine 

The middle meningeal artery additionally plays a role in the oncollection of migraine headaches. The dura mater that the middle meningeal artery burrows right into is a pain-sensitive structure. Dilation of the middle meningeal artery, which is linked through substance P and neurokinin A, results in headaches. Even though dilation of the middle meningeal artery has actually been presented to cause pain regular with migraines, it has been tough to observe middle meningeal artery dilation in the time of the event of a spontaneous migraine.<2> Sumatriptan has actually been presented to alleviate the dilation of the middle meningeal artery. This reduction in the dilation of the middle meningeal artery has actually been connected to diminished pain in patients enduring migraines. While the middle meningeal artery may not be the only factor in migraine headaches, it does play a far-reaching function.

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Chronic Subdural Hematoma

Center meningeal artery embolization is being proposed as a minimally invasive therapy choice for the administration of chronic subdural hematomas, specifically the recurrent ones.<11>