Accuracy of Non-Contrast Brain CT in Pre-Embolization Evaluation of the Middle Meningeal Artery

Purpose Chronic subdural hematoma (cSDH) is typically diagnosed on non-contrast brain CT. Embolization of the middle meningeal artery (MMA) has become an effective and increasingly adopted treatment. However, pre-procedural understanding of MMA anatomy remains crucial, as anatomical variations—such as atypical origins or accessory branches—can affect procedural safety and strategy. This study evaluated whether three-dimensional (3D) reconstructions from routine non-contrast CT can accurately depict MMA anatomy compared with digital subtraction angiography (DSA), the current reference standard. Materials and Methods In this retrospective study, 76 patients (91 MMAs) who underwent both non-contrast CT and DSA were analyzed. The anterior, posterior, and middle branches were assessed. Branch dominance was categorized as Type I (anterior), Type II (posterior), or Type III (mixed), and posterior branch origin as proximal (A), intermediate (B), or distal (C). The Extended-Adachi classification was used for overall anatomical patterns. The foramen spinosum (FS) and MMA tortuosity were also evaluated. Concordance rates between CT and DSA were calculated. Results On CT, the anterior, posterior, and middle branches were visible in 100%, 94.5%, and 96.7% of cases, respectively. CT–DSA concordance was high for branch identification (91.1% anterior, 85.7% posterior, 78.0% middle) and moderate for dominance (45.5%) and posterior origin (39.3%). Absence of the FS on CT was strongly associated with anatomical variants (3 of 4 cases). Conclusion 3D reconstructions from non-contrast CT allow visualization of the main MMA branches and the foramen spinosum. FS assessment on CT provides a valuable indirect marker for identifying anatomical variations and should be systematically included in pre-embolization evaluation.