ReviewClinical neuroradiology2026
Dangerous Ophthalmic Anastomoses During Middle Meningeal Artery Embolization: Anatomical Pitfalls, Hemodynamic Mechanisms, and an Illustrative Case of Delayed Visual Loss.
Review in Clinical neuroradiology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundMiddle meningeal artery embolization (MMAE) is increasingly used for chronic subdural hematoma (cSDH), but dangerous anastomoses between the middle meningeal artery and the ophthalmic circulation remain an underrecognized source of catastrophic visual complications. Standard screening with super-selective angiography and provocative testing may provide false reassurance when occult collaterals are not angiographically apparent.
methodsWe performed a focused narrative review of the literature on MMA-ophthalmic dangerous anastomoses, emphasizing relevant vascular anatomy, angiographic warning signs, embolic hemodynamics, and preventive strategies. These findings were integrated with an illustrative case of delayed monocular blindness following Onyx embolization for cSDH despite negative angiographic and provocative screening.
resultsThis report integrates a single illustrative case nested within a focused narrative review of 30 studies. The reviewed literature and the illustrative case together suggest that negative angiography does not reliably exclude functionally relevant orbital collaterals. In particular, liquid embolics may behave differently from aqueous provocative agents, and pressure-dependent changes during embolization may open otherwise occult pathways to the ophthalmic circulation. In the present case, a 73-year-old man developed irreversible right visual loss approximately 6 h after MMAE, and urgent CT demonstrated punctate retrobulbar hyperdensities along the course of the ophthalmic and posterior ciliary arteries, consistent with non-target embolic deposition within this vascular territory.
conclusionsDangerous MMA-ophthalmic collateralization may remain clinically relevant despite apparently negative pre-embolization screening. Embolization of the anterior MMA division therefore requires heightened caution, particularly when liquid embolics are used. A negative provocative test alone may not reliably exclude this risk.
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