Middle meningeal origin of the ophthalmic artery: a rare case of anatomical variation found in a traumatic brain injury scenario

INTRODUCTION Embolization of the middle meningeal artery (MMA) has been described as an important therapeutic tool in neurosurgery, especially in the treatment of chronic subdural hematoma. However, dangerous anastomoses between the MMA and the ophthalmic artery can occur, influencing the therapeutic approach. AIM To highlight the importance of anatomical variations in cerebral circulation and their clinical impact. CASE REPORT A 23-year-old man presented after a high-impact traffic accident. He was admitted with a Glasgow coma scale score of 15 points, with a reported brief loss of consciousness and anterograde amnesia. Head computed tomography – CT (Figure 1) revealed an epidural hematoma in the right temporal pole, measuring 1.7 cm in thickness. Embolization of the right MMA was indicated to prevent hematoma progression. During the procedure, a rare anastomosis between the right MMA and the right ophthalmic artery was identified, with intense choroidal blush through the right meningo-lacrimal artery (Figure 2). Embolization was not performed due to the risk of right ophthalmic artery involvement. Clinical management and tomographic monitoring were carried out, with no deficits observed on physical examinations and no hematoma progression. DISCUSSION The ophthalmic artery is typically a branch of the internal carotid artery and plays a crucial role in retinal integrity. However, several anomalous origins have been reported in the literature. The MMA origin is the most common variant, observed in 2.2% of angiograms in retrospective studies. The anomalous ophthalmic artery arises from the frontal branch of the MMA, passes through the superior orbital fissure, and supplies the orbit, also giving rise to the central retinal artery. When the ophthalmic artery originates from the MMA, embolization is contraindicated due to the high risk of affecting the central retinal artery, which could result in permanent visual loss. CONCLUSIONS The ophthalmic artery is commonly a branch of the internal carotid artery and plays a crucial role in the integrity of the retina. However, several anomalous origins have been reported in the literature. The MMA origin is the most common variant, found in 2.2% of angiograms in retrospective studies. The anomalous ophthalmic artery arises from the frontal branch of the MMA, passes through the superior orbital fissure, and supplies the orbit, in addition to giving rise to the central retinal artery. When the ophthalmic artery originates from the middle meningeal artery, embolization is contraindicated due to the high risk of affecting the central retinal artery, which could result in permanent visual loss.