Some observations over the article “Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography”

Dear Editor, We read with interest the article entitled “Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography” [1]. The article supplies some original insights on the anatomy of the anastomoses, particularly as far as the caliber of the vessels is concerned. However, we observed that it contains a series of angiographic misinterpretations and a methodologic flaw. The first misinterpretation refers to the artery identified in Fig. 4 as “recurrent meningeal branch”. The artery is actually a “marginal tentorial artery”, a vessel renamed by Lasjaunias et al. [4] as “superficial recurrent ophthalmic artery”. This is a small vessel that mostly originates from the internal carotid artery [3]. However, in 15% of cases it arises from intraorbital vessels (i.e. ophthalmic artery and lacrimal artery) and in 5% of cases from the middle meningeal artery (MMA) [4]. In addition to Lasjaunias’ angiographic demonstration of the artery [4], you can find a couple of recently published examples in Fig. 7B from Macchi et al. [5] and in Fig. 3.5 from Bertelli [2]. In the case of intraorbital origin, the marginal tentorial artery displays a recurrent course that crosses the superior orbital fissure. Indeed, the vessel shown in Fig. 4 is a meningeal artery and has a recurrent course. However, the name “recurrent meningeal branch” is usually reserved to a meningeal branch of the lacrimal artery (LA) which has been reported with a frequency ranging from 58 to 84% of cases depending on the statistical surveys [2]. We believe that this clarification is needed as the terminological confusion is a common and annoying companion of the vascular orbital anatomy. We would also like to point out a second possible misinterpretation in Fig. 4. By the examination of the figure, and without a selective angiography of the external carotid artery (ECA) demonstrating the proximal part of the MMA, it is impossible to affirm if the shown vascular pattern demonstrates a true anastomosis between the LA and the MMA (as the Authors choose to read it) or just an accessory MMA stemming directly from the LA. Figure 3 has been similarly misinterpreted. Again, without the selective angiography of the ECA, it is not possible to know if the proximal part of the MMA does exist. In addition, the supposed anastomosis does not seem to join the ophthalmic artery (OA) and the MMA. Rather, the supposed anastomotic vessel appears to bridge the LA (the LA is visible, though less evident than the anastomosis) and the MMA. Because of the impossibility to ascertain if the vascular patterns are anastomoses with the MMA or just accessory MMAs arising from the orbital vessels, we believe that the article is methodologically flawed. To make a differential diagnosis between the two patterns, a selective ECA angiography is essential. Therefore, the angiographic visibility percentages of the anastomoses reported in the article are probably overestimated as they certainly also include an unspecified number of accessory MMAs arising from the orbit and wrongly interpreted as anastomotic vessels.