Middle meningeal artery aneurysms: Etiology, presentation, management, and outcomes – A systematic review

Background: Middle meningeal artery (MMA) aneurysms are uncommon vascular abnormalities, typically documented through isolated case reports and small case series. Their clinical features, causes, and treatment options are not yet fully understood. Methods: A systematic review of the literature was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included were published case reports and case series that described pure MMA aneurysms. The methodological quality was evaluated with the Joanna Briggs Institute critical appraisal tools for case reports and case series. Data were collected at the individual patient level and summarized descriptively using counts and percentages. Results: Thirty-eight studies comprising 42 patients were included. Male predominance was observed (66.7%). Traumatic (52.4%) and iatrogenic (23.8%) etiologies were most common, with additional vasculopathic, infectious, genetic, and spontaneous causes reported. Most patients presented with intracranial hemorrhage (81.0%), most commonly epidural hematoma. Pseudoaneurysms predominated (78.6%), and distal MMA involvement was frequent (69.0%). Management strategies were heterogeneous, including combined surgical and endovascular treatment (40.5%), endovascular treatment alone (26.2%), surgical treatment alone (23.8%), and conservative management (9.6%). Favorable functional outcomes (modified Rankin scale 0–2) were reported in 88.1% of cases, and mortality was 11.9%. No aneurysm recurrence was reported during available follow-up. Overall risk of bias was moderate, reflecting incomplete reporting inherent to case-based evidence. Conclusion: MMA aneurysms are uncommon, diverse lesions commonly linked to trauma or iatrogenic injury, often presenting with hemorrhage. Treatment approaches are personalized, and prognosis is usually positive. To enhance understanding and inform future management, standardized reporting and collaborative data collection are necessary.