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

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.