Abstract: Objective   To observe and analyze the angiographic anatomy of middle meningeal artery (MMA) in patients with chronic subdural hematoma (CSDH) and explore its value of guiding MMAE strategy.  Methods   102 MMA angiographic anatomic images of 80 CSDH patients from March 2019 to March 2023 were collected. Independent evaluation was performed by two senior neurointerventional physicians, MMA classification was performed by reference to Adachi classification. The MMA classification, origin and variation, dangerous anastomosis, embolization strategy, operation-related complications and postoperative recurrence were recorded.    Results    A total of 101 MMAs (79 cases) were classified. Type I were observed in 44/101 (43.6%) MMAs, and the results were moderately consistent (Kappa=0.54, 95% CI: 0.39-0.69). Type A were observed in 32/101 (31.7%) MMAs, and the results showed strong consistency (Kappa=0.84, 95% CI: 0.72-0.96). Out of 102 MMAs, only 1 (1.0%) MMA variously originated from the ophthalmic artery (OA). In 2 of these 102 (2.0%) MMAs, OA originated from MMA. The anastomosis with OA via collateral branch was observed in 5/102 (4.9%) MMAs and the anastomosis with the contralateral MMA branches was observed in 8/102 (7.8%) MMAs. Radiographic recurrence occurred in 2 cases during postoperative follow-up.    Conclusions    It is of great clinical significance to be familiar with MMA angiographic anatomy, especially the classification of MMA and the possible dangerous anastomosis, to guide the selection of embolic agents and the formulation of embolic strategies for MMAE treatment of CSDH, and to improve the efficacy and safety of endovascular embolization treatment of CSDH.  

Key words: Anatomy,  ,  , Dangerous anastomosis,  ,  , Chronic subdural hematoma,  ,  , Middle meningeal artery embolization