Unexpected ocular morbidity after middle meningeal artery embolization: Lessons learned from a case of anastomotic-related diplopia.

Middle meningeal artery embolization (MMAE) has revolutionized chronic subdural hematoma management, yet procedural risks persist due to anatomical variability. We analyze a case report by Zhao et al describing transient diplopia caused by inadvertent embolization of the lacrimal artery via a dynamic middle meningeal-ophthalmic anastomosis. This correspondence advances three critical innovations in MMAE safety. First, intraoperative anastomotic unmasking-exposing occult middle meningeal-ophthalmic collaterals during particle injection-reveals dynamic vascular behavior missed by preoperative angiography, underscoring the need for adaptive imaging protocols. Second, hybrid embolization (liquid agents for proximal occlusion + particles for distal control) balances precision and safety, reducing reflux risks compared to monotherapy. Third, a 108-day follow-up establishes a benchmark for functional recovery, challenging assumptions about irreversible cranial nerve injuries and emphasizing structured postprocedural care. Collectively, these findings advocate for procedural agility, multimodal embolic strategies, and sustained rehabilitation to optimize MMAE outcomes while minimizing iatrogenic harm.