Real-time DSA-guided foreign body removal in transorbital orbitocranial penetrating injuries: report of two cases

Abstract

Introduction and importance:

Transorbital orbitocranial penetrating injuries (TOPI) are lesions in which a foreign object penetrates the orbit and enters the intracranial cavity through the skull base. These injuries have a high rate of mortality and disability and pose a challenge for surgical treatment.

Case presentation:

We report two cases of TOPIs caused by metallic foreign bodies that were managed with foreign body removal under the guide and vision with cerebral digital subtraction angiography (DSA).

Clinical discussion:

In our cases, the trajectory of the wound through the aerated spaces of the maxillofacial-orbital region, the inability to control the entry point at the skull, and the proximity of the foreign body to major blood vessels at the skull base are key challenges in their management. DSA provided continuous, real-time monitoring for vascular injuries during extraction. A multidisciplinary approach to treat is essential in managing this pathology.

Conclusion:

TOPIs are rare injuries. To date there are no guidelines for their treatment. In some selected cases, a multidisciplinary team, involving the neurosurgeon, neurovascular interventist, and resuscitation teams, helps minimizes risks to the patient.

Introduction

Transorbital orbitocranial penetrating injury (TOPI) occurs when a foreign object penetrates the orbit into the cranial cavity via the skull base. Although less common than closed head injury, accounting for only 0.4%^[1] of head injuries in general, TOPI has a high mortality rate of 33–53%,^[2] with significantly higher rates of vascular injury and disability exceeding 50%^[3].

Treatment goals of TOPI include foreign-body removal, preservation of critical skull base neurovascular structures with minimal brain injury during foreign object removal, limitation of additional risk of orbital-visual injury and infection control. Due to the complexity and rarity of TOPI, no general treatment protocol or guideline exists to date.

The treatment strategy is often developed case-by-case, requiring multidisciplinary collaboration between neurosurgery, neuro-interventional, ophthalmology, and intensive care specialties. We describe two TOPI cases that were managed at our institution using a common strategy, while presenting our strategy for this type of injury and reviewing treatments in the literature. Digital subtraction angiography (DSA) is a fluoroscopic technique used in interventional radiology that allows physicians to clearly visualize blood vessels. Radiopaque structures are digitally subtracted from the image, enabling clear visualization of the vasculature. The use of real-time DSA for foreign body extraction has not been previously reported in the literature, with these two cases being the first documented applications of this technique in Vietnam. This method shows that in selected cases, safe foreign body removal can be achieved without requiring craniotomy. These case reports have been reported in line with the SCARE Guidelines^[4].

HIGHLIGHTS

• Two cases of transorbital orbitocranial penetrating injuries caused by metallic foreign bodies.

• Real-time DSA facilitates safer foreign body retrieval, minimizing injury to critical neurovascular structures.

• Multidisciplinary treatment, including neurosurgery, neurovascular intervention, and resuscitation is a safe option and minimizes risks for the patient.

Cases report

Case 1

A 17-year-old male with no prior medical history presented to the emergency after a motorcycle-car collision. Upon arrival, GCS was 12 with right hemiparesis. Vital signs were stable. A smooth, blunt-tipped metallic foreign body penetrated the left orbit (Fig. 1A), while the right eye showed no abnormalities. The left globe was intact with positive pupillary light response. Computed tomography (CT) scan demonstrated a 17-cm radiopaque metallic rod entering the medial wall of the left orbit, beneath the roof of the posterior ethmoid and sphenoid sinus, traversing the sellar region, then deep to the right inferior cerebral peduncle, adjacent to the pons. The intracranial segment of the foreign body measured approximately 12 cm (Fig. 1B and C). CT angiography (CTA) revealed no cerebrovascular injury. The foreign body was near the medial margin of the cavernous-segment right ICA and abutted the right PCA (Fig. 1D–F). DSA confirmed no circle of Willis injury (Fig. 2A–D). Laboratory investigations on admission demonstrated no abnormal findings.

Figure 1.

Image of the foreign object embedded in the patient’s orbit upon hospital admission (A). Lateral X-ray (B), axial CT (D–F) and 3D reconstruction CT (C) demonstrated the trajectory of the foreign object, which penetrates from the medial aspect of the left orbit through the ipsilateral frontal skull base, crosses to the suprasellar region, and stops at the lateral aspect of the brainstem on the contralateral side.

Figure 2.

DSA demonstrated that the left anterior circulation (A and B) and posterior circulation (C and D) remain intact along the long trajectory of the foreign body. After foreign body removal, both anterior and posterior circulations were preserved (E–G). The foreign body is metallic, 17 cm in length, with the intracranial portion measuring approximately 12 cm (H).

Removal was performed in the angiography suite with three coordinated teams: Team 1 (Interventional neuroradiology) conducted pre- and post-procedure DSA and endovascular standby for complications; Team 2 (Neurosurgery) extracted foreign-body after diagnostic DSA; Team 3 (Neurosurgery/Anesthesiology) were in operating room with microscope on standby.

After Team 1 confirmed no significant cerebrovascular injury, Team 2 slowly withdrew the foreign body retrogradely under real-time DSA, with clear visualization of vessels (Fig. 2E–H). The distal end of foreign body was caught at the orbital roof causing difficulties, but was eventually removed. The total duration from anesthesia induction to foreign body extraction was 1 hour. A post-extraction DSA confirmed no major vascular injuries. After 1 hour monitoring in the ICU, the patient underwent a follow-up CT scan, revealing a diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and parenchymal hemorrhage in the posterior limb of the right internal capsule (Fig. 3A–D). A neurosurgery-anesthesiology consultation agreed upon a conservative approach, including continuous monitoring in the ICU and CT scans every 24 hours (Fig. 3E). On day 7, the patient was transferred to the inpatient ward, alert with improved hemiparesis. A CT scan showed subarachnoid hemorrhage regression (Fig. 3F). Broad-spectrum antibiotic coverage with a third-generation cephalosporin (Intravenous Ceftriaxone 2 g daily) was administered for 10 days. No signs of meningitis or cerebrospinal fluid leak were present. Residual right hemiparesis persisted, and the patient was discharged after 15 days. The patient was followed up at 1 month and 3 months to assess the progression of cerebral contusion and to exclude pseudoaneurysm formation.

Figure 3.

Axial CT scan within 24 hours after foreign body removal demonstrated subarachnoid hemorrhage and intraventricular hemorrhage (A–D). After 3 days, the intraventricular hemorrhage decreased with a remaining cerebral contusion in the posterior limb of the left internal capsule (E). After 10 days, the intraventricular hemorrhage had nearly completely regressed (F).

Case 2

A 20-year-old male patient with no prior medical history presented after crashing into an iron stake while riding a motorbike. The rescue team had to saw off part of the metal bar before transporting the patient to our hospital. On arrival, GCS was 13 with left hemiparesis. Vital signs remained stable. Examination revealed a smooth-edged, metallic foreign body penetrating from the inferior aspect of the left orbit, with no abnormalities in the right eye (Fig. 4A and B). CT showed a foreign body measuring 118 × 12 mm, coursing left to right, anterior to posterior, and inferior to superior. The entry point was at the nasal region adjacent to the left orbit inferomedial margin, passing through the bilateral ethmoid and right sphenoid sinuses, immediately adjacent to the right optic canal, and entering the right temporal middle cranial fossa. Surrounding the foreign body tip, there was a 10 × 12 mm contusion and hematoma in the right temporal lobe with bone fragments lodged in the brain tissue. No cerebrovascular injury were detected (Fig. 4C–E). Admission blood tests revealed no abnormalities.

Figure 4.

Images of the foreign object penetrating the patient’s facial region upon hospital admission (A and B). X-ray (C) and CT (D) demonstrated the foreign object penetrating from the maxillary sinus through the inferior-medial wall of the right orbit, through the orbital apex into the middle cranial fossa, stopping at the lateral aspect of the right cavernous sinus. CTA (E) and CT (F) after foreign object removal demonstrated no vascular injury and a small brain contusion in the right temporal base.

The patient underwent a protocol similar to Case 1 with a total duration of 1 hour (Fig. 5). A CSF leakage through the wound was managed with lumbar drain placement for 5 days, draining approximately 150 ml daily. Antibiotic therapy was similar to that of Case 1. The patient remained stable with absence of new neurological injury, CSF leak, or meningitis. As in Case 1, no cerebral pseudoaneurysms were detected at 1 month and 3 month follow-ups. Both patients demonstrated early neurological recovery without seizure activity, thus ICP monitoring and prophylactic anticonvulsants were not indicated. The second case involved foreign body trajectory through the superior maxillary sinus. Maxillofacial surgery consultation was obtained, and no further intervention was recommended following foreign body extraction.

Figure 5.

DSA shows the vessels of the right anterior circulation remain intact before (A and B) and after (C and D) foreign object removal. CT within 24 hours after foreign object removal (E) demonstrated intraventricular hemorrhage and subarachnoid hemorrhage. Follow-up MRI at 1 week (F) demonstrated right temporal brain contusion around the foreign object trajectory. Follow-up CT at 1 month (G and H) shows resolution of intraventricular hemorrhage and brain contusion.

Both patients underwent ophthalmological assessment before foreign body retrieval. Globe integrity and optic nerve function were preserved in both cases. Visual acuity showed improvement in both patients at the 3-month follow-up examination.

Discussion

Transorbital orbitocranial penetrating injuries (TOPI) are relatively rare, accounting for 0.4% of all traumatic brain injuries, and more commonly seen in children than adults (45% vs 24%, respectively)^[5,6]. These injuries are categorized into two groups: high-energy and low-energy injuries. Non-ballistic penetrating injuries fall into the low-energy group, with entry points usually through thinner parts of the skull, such as the temporal squama, foramen magnum, or orbit^[7]. The intracranial trajectory and extent of surrounding tissue destruction of the foreign body depend on its direction, velocity, and neighboring neurovascular anatomy^[8]. Risk of major skull base cerebrovascular injury is assessed by the foreign body trajectory in proximity to the circle-of-Willis, an entry wound over the frontobasal-temporal regions, an interhemispheric fissure- traversing trajectory, and a subarachnoid hemorrhage on CT^[9].

Imaging is crucial in managing foreign body TOPIs, with CT as the first-line modality regardless of the foreign body material^[10]. However, CTA may produce artifacts when metallic foreign bodies are involved, limiting the visualization of major cerebral vessels compared to DSA^[11]. MRI is contraindicated in metallic and metallic-suspected foreign bodies, but often used in follow-up monitoring due to its superiority in detecting cerebral contusions, ischemic lesions, cerebral edemas, axonal injuries, or brain abscesses^[10]. DSA is the most reliable modality for assessing major skull base vascular injury, cerebral blood flow, and bleeding risk during foreign body extraction^[10,12]. In our two cases, DSA provided continuous, real-time monitoring for vascular injuries during extraction. A combined approach using CT–CTA and DSA to assess parenchymal injury, hemorrhage status, and risk to Circle-of-Willis arteries was applied to both patients.

The orbital entry site of the foreign body also correlates with ocular, skull base, and intracranial damage. Based on the anatomical classification of injuries, Turbin et al^[13] divided the orbital surface into four zones. Zone 1 includes central, lateral, unspecified upper lid, or superior conjunctival entry points. Zone 2 includes central, lateral, unspecified lower lid, or inferior conjunctival entry points. All medial and canthal penetrating wounds are classified as Zone 3 injuries, further subdivided into subzones a, b, and c (superior, middle, and inferior, respectively). Zone 4 represents upper and lower eyelid lacerations and conjunctival injuries that are not medial in location (Zone 1 + Zone 2). They reported that up to 83.3% of patients with zone 1 injuries (as in Case 1) had orbital roof fractures, frontal lobe brain abscesses, orbital encephalomeningocele, cerebral contusions, and bone fragments within the brain. In contrast, zone 3c entry (as in Case 2) typically causes damage to the brainstem, temporal lobe, and cavernous sinus^[13]. For comatose patients, ICP monitoring is commonly recommended. Wu et al suggest that further research is needed to evaluate the role of ICP monitoring in managing TOPIs caused by foreign bodies^[10].

To date, there are no standardized treatment protocols for TOPIs caused by foreign bodies^[10]. Most authors agree on the following treatment principles: removal of the foreign body, local wound debridement, decompression of neurovascular structures, hemostasis, and dural closure^[7]. Major vascular injury hemorrhage during foreign body extraction, although rarely reported, is a fatal complication that must be anticipated, monitored, and managed promptly^[10,14]. Temporary or permanent occlusion of the injured artery should be considered prior to foreign body removal^[15]. The Balloon Occlusion Test is an essential pre-procedural assessment of the feasibility of ICA sacrifice, a practice implemented routinely at our center. In emergencies, bypass surgery may be considered as a backup if ICA occlusion becomes necessary^[16].

Our strategy included: assessing relationship between foreign body and major vessels on CT/CTA/DSA; retrograde extraction of the foreign body under DSA guidance, following principles of Ildan^[17] and Oguz^[18], but with the distinction of real-time DSA of major arterial injury during extraction; checking for hemorrhage on CT. Neither patients required surgical intervention because no arterial or venous complications were detected. Antimicrobial therapy followed standard protocols. Real-time DSA monitoring of major vascular injury – similar to approach by Riley et al^[19] – enabled immediate endovascular therapy if injury appeared. Most circle of Willis injuries during foreign body extraction will consist of lateral arterial wall wound, for which surgical clip placement risks narrowing or sacrificing the artery. Endovascular management is therefore “less burdensome” than surgery, if needed. Notably, significant vascular injury during pre-hospital self-extraction by patients has not been reported^[5,8,10]. Our approach enabled patients to avoid craniotomy and cerebral tissue disruption for foreign body retrieval, despite maintaining a prepared surgical team in the operating theater for emergent craniotomy conversion in case of hemorrhage or vascular injury during the extraction process.

CSF leak during foreign body extraction is also a notable concern. We prophylactically placed a lumbar drain, similar to management of basilar skull fractures or post-endoscopic skull base surgery. Neither patient developed CSF leaks post-procedure. CSF leakage was also not reported in a patient who self-extracted the foreign body who received conservative management^[20].

The outcomes of TOPIs depend not only on early complications, such as major vascular injuries near the Circle of Willis, but also on delayed complications, such as cerebral vasospasm after subarachnoid haemorrhage, traumatic pseudoaneurysms, arterial dissection, and infection^[10,11]. Base on our experience, the overall prognosis remains favorable when the brainstem and major vasculature are spared from injury. Post-traumatic extracranial sequelae include ptosis, vision loss, or oculomotor dysfunction. The most common intracranial complication is intracranial hemorrhage, followed by infection, cranial nerve injuries, ischemia, pseudoaneurysm, arteriovenous fistula, venous sinus thrombosis, epilepsy, ventricular dilation, and CSF leakage^[8,10,14].

Our study has some limitations, including a small number of patients, the absence of a control group for comparison with other approaches. One key risk is venous bleeding, especially from venous sinuses, which are difficult to visualize on DSA. Wu et al^[10] addressed bleeding from the cavernous sinus using electrocautery and direct compression. In our cases, we opted for clinical monitoring and non-contrast cranial CT imaging to evaluate bleeding from small vessels or venous sinuses. In cases where the intracranial portion of the foreign body is large or has barbs or branches (such as arrows, fishhooks, etc.), its retrieval under DSA guidance may not be feasible as this portion could become lodged against the skull base or cause injury to critical neurovascular structures. In such situations, craniotomy should be performed in combination to release the intracranial portion of the foreign body prior to its retraction under DSA guidance.

Conclusion

Transorbital orbitocranial penetrating injuries due to foreign bodies are rare injuries, and to date, there are no guidelines for their treatment. Surgical removal of foreign bodies, control of bleeding, and prevention of infection are the consensus of most authors. In some selected cases, multidisciplinary treatment, including neurosurgery, neurovascular intervention, and resuscitation, is a safe option and minimizes risks for the patient.

Ethical approval

Our institution does not require ethical approval for reporting individual cases.

Consent

A written consent was received from the parents’ patient. In such case, the anonymised presentation of case report does not required a separate approval by the ethics committee.

Sources of funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

D.P., S.T.T., L.M.T.N., D.D.N., M.Q.N., and H.M.N.: study concept, data collection, data analysis, writing the paper; D.P., M.Q.N., and H.M.N.: reviewing and correction of the paper.

Conflicts of interest disclosure

The authors have no conflict of interest to declare.

Research registration unique identifying number (UIN)

None.

Guarantor

Duy Pham.

Acknowledgements

None.