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. 2019 Mar 29;32(3):158–165. doi: 10.1177/1971400919840843

Clinical importance of the posterior meningeal artery: a review of the literature

Guangming Wang 1, Jing Yu 2, Kun Hou 1, Yunbao Guo 1, Jinlu Yu 1,✉
PMCID: PMC6512203  PMID: 30924401

Abstract

The posterior meningeal artery, which arises from the vertebral artery, is a critical artery in neurological lesions. However, a comprehensive review of the importance of the posterior meningeal artery is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the posterior meningeal artery to increase our understanding of its role in vascular lesions. The posterior meningeal artery provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The posterior meningeal artery is often involved in dural arteriovenous fistulas occurring near the posterior fossa, and the posterior meningeal artery can be the path for transarterial embolisation or a path through which to monitor the degree of dural arteriovenous fistula embolisation. In posterior circulation ischaemia and moyamoya disease, the posterior meningeal artery can form transdural anastomoses with pial arteries at the surface of the brain, and these can help prevent ischemia. The posterior meningeal artery can also develop aneurysms, most of which are traumatic pseudoaneurysms; patients should therefore be treated in a timely manner or followed up carefully in cases of rebleeding. In addition, during a craniotomy, the posterior meningeal artery should be protected intraoperatively to avoid damaging any transdural anastomosis that may be present. In addition, when the posterior meningeal artery is the main feeding artery of an intracranial tumour, that artery is a satisfactory path for preoperative embolisation. Briefly, the posterior meningeal artery is a very important artery in neurosurgery.

Keywords: Posterior meningeal artery, importance, review

Introduction

The posterior meningeal artery (PMA), at times identified as the artery of the falx cerebelli, usually arises from the vertebral artery (VA).1 The PMA can be involved in dural arteriovenous fistulas (DAVFs), the collateral circulation in posterior circulation ischaemia, moyamoya disease (MMD), aneurysms and intracranial tumours.2–5 In addition, the PMA should be protected to avoid damaging any transdural anastomoses that may be present.6

Hence the PMA is a very important vessel in neurological lesions. However, a comprehensive review of the importance of the PMA is currently lacking. Here, we have performed a review to increase understanding of the role played by the PMA. ‘Posterior meningeal artery’ was used as a search term in the PubMed database to identify relevant English-language publications.

Anatomy of PMA

The PMA usually arises from the third segment of the VA.7 Occasionally, the PMA can arise from the fourth segment of the VA. The PMA may also originate from the occipital artery,8–10 ascending pharyngeal artery,11 cervical internal carotid artery,12 or posterior inferior cerebellar artery (PICA).13,14 The above-mentioned PMA variations may result from events during embryological development.13

The PMA can be divided into an extracranial and an intracranial segment; the extracranial segment is tortuous, probably as an adaptation to the motility of the neck.15 The intracranial segment is relatively straight.16 The common origins of the PMA are shown in Figure 1. The segments of the PMA are shown in Figure 2.

Figure 1.

Figure 1.

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Origin of the PMA from the VA. (a) DSA of the VA showing that the PMA arose from the third segment of the VA (arrow). (b) DSA of the VA showing that the PMA arose from the fourth segment of the VA (arrow). PMA: posterior meningeal artery; VA: vertebral artery; DSA: digital subtraction angiography.

Figure 2.

Figure 2.

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Segments of the VA. DSA of the VA showing that the PMA can be divided into extracranial and intracranial segments. The extracranial segment is tortuous (single arrow), whereas the intracranial segment is relatively straight (double arrows). VA: vertebral artery; DSA: digital subtraction angiography; PMA: posterior meningeal artery.

After its origin, the PMA runs in the groove for the VA on the upper edge of the posterior arch of the atlas towards the posterolateral edge of the foramen magnum, where it enters the intracranial dura.1 Then, the PMA ascends nearly parallel to the internal occipital crest to reach the dura over the medial cerebellar fossae and falx cerebelli and passes above the torcula to reach the dura of the falx cerebri.17

The PMA provides the main blood supply to the paramedial and medial portions of the dura that covers the cerebellar convexity between the transverse sinus and torcula above and the posterior edge of the foramen magnum below, but this area also receives contributions from the middle meningeal arteries (MMAs) and occipital artery branches.8,18

Dural arteriovenous fistula

Intracranial DAVFs are abnormal arteriovenous connections that lie within the dura.19,20 The feeding arteries of DAVFs depend on their location, and the blood supply usually comes from the meningeal arteries or the meningeal branches of the external carotid arteries.21,22 As a feeding artery, the PMA is often involved in DAVFs of the tentorium, torcula, transverse-sigmoid sinus, or cervicomedullary junction.2,10,23 There are even cases in which the PMA is the only feeding artery of a DAVF.24,25

Currently, endovascular embolisation is the first-line treatment for intracranial DAVFs.26 In DAVF embolisation near the posterior fossa, the PMA can play two roles: it can act as the path for transarterial embolisation and as the path for monitoring the embolisation.23,27 For instance, in a 2009 study by Stiefel et al., 28 patients were treated with 40 Onyx (ev3 Neurovascular, Irvine, CA, USA) procedures in which eight PMA branches were used for embolisation.28

When performing a DAVF embolisation by way of the PMA, one should be on the alert for certain rare complications. For instance, in a 2017 study, Crockett et al. performed PMA dimethyl sulphoxide (DMSO) injection prior to Onyx therapy for a tentorium DAVF, and a reproducible asystole occurred from the trigeminocardiac reflex; this complication arose because chemical stimulation of regions of the posterior fossa dura innervated by branches of the vagus nerve led to increased parasympathetic activity and resultant asystole.29

However, the PMA is sometimes so tortuous or slender that it is difficult to use as a vascular access route for endovascular embolisation.24 In those cases, a surgical approach must be used; for instance, in a 1997 study, Niwa et al. reported two cases with DAVFs of the cervicomedullary junction that were fed by the PMA that were successfully treated by surgical interruption of the intrathecal vein with coagulation.30

In a DAVF located in the transverse sigmoid sinus, the PMA was used as a path by which to monitor the embolisation, as illustrated in Figure 3.

Figure 3.

Figure 3.

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A DAVF in the transverse-sigmoid sinus. (a) and (b) DSA of the external carotid artery and VA showing that the DAVF is supplied by the MMA and PMA (arrow) and drained by the cortical veins. (c) Unsubtracted image showing the Onyx cast in the DAVF by way of the MMA. (d) DSA of the VA showing that the PMA was used as the path by which to monitor the embolisation; the results demonstrate that the DAVF was completely embolised. DAVF: dural arteriovenous fistula; DSA: digital subtraction angiography; VA: vertebral artery; MMA: middle meningeal artery; PMA: posterior meningeal artery.

Collateral PMA–PICA circulation

For dissecting aneurysms on the PICA trunk, the aggressive occlusion of both the PICA aneurysm and its parent artery is the best option.31,32 However, this radical embolisation procedure carries the risk of brainstem and cerebellar ischaemia, although the terminal branches of the PICA anastomose with neighboring vessels, including, among others, the anterior inferior cerebellar artery, the contralateral PICA and the superior cerebellar artery (SCA), which can support the viability of the brain.33

Rarely, after occlusion of the PICA trunk, hypoperfusion of the terminal branches of the PICA territory can trigger collateralisation by transdural PMA–PICA anastomoses.6 Normally, no anastomosis are located between the PICA and the PMA, but pre-existing anastomotic channels between the primitive vessels of the PICA and PMA that arise during embryonic development sometimes persist until adulthood and may develop further, resulting in the rare phenomenon of collateral PMA–PICA circulation.13,34

In this paper, we reviewed the literature and identified four cases with PMA–PICA circulation; these cases are summarised in Table 1 and were reported by Tsutsumi et al. in 2007,7 Chang et al. in 2009,6 Arai et al. in 201235 and Hou et al. in 2018.5 These patients initially had no PMA–PICA anastomoses; however, after the PICA trunk was occluded, PMA–PICA anastomosis developed. This type of anastomosis is uncommon and should not be expected to occur.

Table 1.

A summary of PICA–PMA anastomosis.

First author, year Age/gender (years) Symptom Disease Treatment Time of discovery of anastomosis Prognosis
Tsutsumi, 20077 38/M Wallenberg’s syndrome Dissecting aneurysm of the PICA Endovascular occlusion of the aneurysm and parent artery 1 Week after treatment No additional neurological deficits
Chang, 20096 56/M SAH PMA aneurysm Successful clipping 4 Weeks after onset Good
Arai, 201235 53/M Severe headache, later Wallenberg syndrome PICA-involved dissecting aneurysm of the VA Conservative treatment 3 Weeks after onset No additional neurological deficits
Hou, 20185 29/F SAH Dissecting aneurysm of the PICA Endovascular occlusion of the aneurysm 6 Months after treatment Good
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PICA: posterior inferior cerebellar artery; PMA: posterior meningeal artery; M: male; F: female; SAH: subarachnoid haemorrhage; VA: vertebral artery.

MMD and posterior circulation ischaemia

The PMA forms the infratentorial limb of the arcade supplying the falcotentorial junction and may anastomose with the tentorial branch of the posterior cerebral artery (PCA),36,37 the tentorial branch originating from the SCA38 or the tentorial artery.39,40 These potential collateral channels have an embryological origin but may reopen or expand as an unusual collateral pathway in MMD or posterior circulation ischaemia.41,42

MMD is characterised by progressive stenosis of the intracranial internal carotid arteries and their proximal branches, leading to the development of collateral circulation through small moyamoya-like vessels.43 MMD mainly involves the anterior circulation of the brain, but involvement of the posterior circulation has been reported in MMD and may occur by a process involving the basilar arteries and PCAs.42

In anterior circulation MMD, MMAs can penetrate the dura to anastomose with pial arteries.18,44 Therefore, analogous to the MMAs in anterior circulation MMD, the PMA should theoretically undergo similar pathophysiological processes in MMD and ischaemia of the posterior circulation.45 For instance, in 1984, Miyamoto et al. reported a case of MMD associated with bilateral occlusion of the VA in which there was transdural anastomosis between the SCA and the PMA.46

Here, we identified two patients with PMA transdural anastomosis. Patient 1 had vertebrobasilar stenosis, which led to moyamoya-like vessels in the PICA territory; because of the insufficiency of the PCAs, a transdural PMA–PCA anastomosis was established (Figure 4(a)). Patient 2 had MMD of the posterior circulation. The PMA developed transdural anastomoses in the occipital region and falcotentorial junction (Figure 4(b)).

Figure 4.

Figure 4.

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Transdural anastomosis of the PMA. (a) DSA of the VA showing vertebrobasilar stenosis, moyamoya-like vessels in the PICA territory, and an established transdural PMA–PCA anastomosis. (b) DSA of the VA showing MMD of the posterior circulation. The PMA had developed transdural anastomoses in the occipital region and falcotentorial junction. PMA: posterior meningeal artery; DSA: digital subtraction angiography; VA: vertebral artery; PICA: posterior inferior cerebellar artery; PCA: posterior cerebral artery; MMD: moyamoya disease.

PMA aneurysm

Spontaneous true aneurysms of the PMA are considered a poorly understood event.47,48 These aneurysms are often associated with pathological conditions, such as DAVFs and tumours, and they are often unruptured. Under these pathological conditions, the PMA carries high blood flow and haemodynamic stress.49–51 These aneurysms had a chronic onset and a long history that enabled sufficient preoperative preparation.

In addition to true aneurysms, pseudoaneurysms can occur, and these are usually associated with blunt trauma that results in incomplete disruption of the PMA wall.52,53 As a result of their fragile architecture, PMA pseudoaneurysms tend to enlarge and rupture, resulting in haemorrhage in the epidural space, subdural space or the brain parenchyma depending on the location of the aneurysm and the resistance of the surrounding tissue.47,48,54,55

Follow-up digital subtraction angiography (DSA) should be considered to detect PMA pseudoaneurysms in cases of rebleeding. In the meantime, immediate treatment is indicated. Both surgical and endovascular treatment are effective; however, regardless of which method is used, both the aneurysm and the parent artery should be excised or occluded together.51,52

In this paper, we reviewed the literature and found seven cases with PMA aneurysms that were reported by Toro et al. in 1993,48 Okuno et al. in 1998,50 Higurashi et al. in 2002,47 Aronson et al. in 2008,1 Muro et al. in 2010,49 Goetz et al. in 201152 and Raygor et al. in 2014.51 These cases are summarised in Table 2. Among the seven cases, there were three true aneurysms and four pseudoaneurysms. The pseudoaneurysms tended to have a worse prognosis.

Table 2.

A summary of PMA aneurysms.

First author, year Age/gender (years) Onset Associated disease Aneurysm location Type Aneurysm treatment Prognosis
Toro, 1993 48 22/M Intraventricular haemorrhage, posterior fossa epidural haematoma and right occipital skull fracture – On the trunk of the PMA False Cauterisation Death
Okuno, 199850 55/F SAH in the posterior fossa PMA arising directly from the PICA At the origin of the PMA from the PICA True Successful clipping Completely free from neurological deficits
Higurashi, 2002 47 – SAH, subdural haemorrhage and midline skull fracture in the posterior fossa – On the trunk of the PMA False En bloc excision No major neurological deficits
Aronson, 20081 65/M SAH in the posterior fossa PMA arising from the PICA At the origin of the PMA from the PICA False Coagulation of the pseudoaneurysm and transection of the PMA Neurologically intact
Muro, 201049 29/F Unruptured DAVF On the trunk of the PMA True En bloc excision A nearly complete neurological recovery
Goetz, 201152 63/F Recurrent SAH, fracture of the occipital bone and subdural haematoma – On the trunk of the PMA False Coiling occlusion Severe impairment of consciousness
Raygor, 201451 23/F SAH and ventricle haemorrhage in the posterior fossa Haemangioblastomas On the trunk of the PMA, embedded in the tumour True Embolisation and excision of the right PMA Death
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PMA: posterior meningeal artery; M: male; F: female; SAH: subarachnoid haemorrhage; DAVF: dural arteriovenous fistula.

Other clinical importance

Intraoperative PMA protection

In most cases, the PMA is slender, and there is an abundant blood supply from other meningeal arteries; this allows the proximal PMA to be occluded without compromising the falx cerebelli.34,56 However, in rare cases, the PMA can form collateral circulation with the PICA; under those circumstances, if the dura is opened for a far-lateral approach, the sacrifice of the PMA upon dissection will cause an ischaemic stroke in the posterior circulation.6,57

Therefore, in some operations performed in the posterior fossa, especially in high-flow vascular diseases, the PMA should be carefully evaluated by DSA before surgery.

Epidural haematoma

Traumatic posterior fossa epidural haematoma may be caused by the rupture of the PMA from the occipital fracture.58,59 However, the PMA may occasionally rupture without bone fracture; in these cases, it may be that a deformity in the occipital bone injured the PMA. For instance, in 1907, Ryfkogel et al. reported a 25-year-old male patient without occipital fracture in whom a PMA rupture was discovered to have caused posterior fossa epidural haematoma.60

Therefore, in posterior fossa epidural haematoma, the PMA should be carefully evaluated by DSA.

Intracranial tumour

Preoperative embolisation of intracranial tumours has been shown to be highly effective in reducing intraoperative blood loss.61 The PMA is a satisfactory path by which to perform a preoperative embolisation.62,63 However, during embolisation, the uncontrolled migration of embolisation material is the most dangerous complication and should be avoided as it can result in acute ischaemic strokes.64

Conclusion

The PMA is a very important artery that provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The PMA can be involved in DAVF treatment as the path of transarterial embolisation or as the path by which the embolisation is monitored. Hypoperfusion through the PICA can, after a delay, induce endogenous revascularisation of the PICA territory by way of PICA–PMA transdural anastomoses, and this may help to prevent distal PICA ischaemia. In MMD and ischaemia of the posterior circulation, the PMA can form transdural anastomoses with pial arteries at the surface of the brain. The PMA can develop true aneurysms and pseudoaneurysms, and most such pseudoaneurysms are traumatic. Follow-up should be considered to detect PMA pseudoaneurysms in cases of rebleeding. True aneurysms of the PMA are associated with pathological conditions and have a better prognosis. In addition, the PMA should be protected intraoperatively to avoid damaging any transdural anastomoses that may be present. When the PMA is the main feeding artery of an intracranial tumour, it is a satisfactory path for preoperative embolisation.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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