transorbital intracranial injury is rare and may cause serious brain damage and is associated with a high mortality rate .
this type of injury , accounting for 4.5% of all orbital pathology,[35 ] represents 0.04% of all head trauma , 24% of penetrating head trauma in adults , and 45% in children .
penetrating orbital injury may lead to severe brain injury when the foreign object enters the cranium , leading to both orbital and cerebral complications .
a foreign body can penetrate the brain through the orbit in 3 ways : via the orbital roof , the superior orbital fissure , and the optic canal .
the diagnosis is confirmed if an entire or partial foreign object is found in the wound , and is difficult to make in the case of trivial trauma .
we report a case of a transorbital injury caused by penetration of a metal bar which entered the cerebrum through the orbit .
a 13-year - old male sustained an injury to his right orbit , resulting from falling while holding a metal bar . an iron bar [ 3 cm  18 cm ] penetrated his right orbit via the medial canthus and right infraorbital region and was driven into the skull . on admission , he was unconscious , but with normal vital signs .
his right eye protruded outside the orbital cavity and was severely swollen and bruised . on neurological examination , he was in a deep coma with a glasgow coma score of 4/15 ( e1m2v1 ) .
plain skull radiographs confirmed that the bar crossed the skull from the right orbit to the left occipital bone [ figure 1 ] .
computed tomography ( ct ) demonstrated the bar passing through the right orbit and superior orbital fissure and emerging from the left occipital bone , which was fractured by direct compaction . in association with the bar
, there was a trajectory of intracerebral hemorrhage , specifically subarachnoid hemorrhage in the basal cisterns with severe cerebral edema [ figure 2 ] .
the bar penetrated the third ventricle and suprasellar cistern ; adjacent to the right carotid artery and branches , the dense hemorrhage observed within the suprasellar cistern was likely the result of injury to the right internal carotid artery .
angiography could not be performed because the patient rapidly worsened neurologically ( gcs 3 : e1m1v1 ) .
lateral skull radiograph shows the bar penetrating the orbit and emerging from the occipital bone .
computed tomography demonstrates the bar 's trajectory into the sellar and suprasellar region via the superior orbital fissure .
the right internal carotid artery was found to be lacerated , and the right optic nerve and optic chiasm transected near the superior orbital fissure .
the bar penetrated the superior orbital fissure , anterior clinoid process , suprasellar cistern , third ventricle , and cerebrum .
incidentally , if a metal bar is fixed at the superior orbital fissure , it can usually be mobilized and removed , retracting it carefully from the entry site under direct visualization and avoiding resistance or leverage .
severe bleeding from the right internal carotid artery occurred despite this maneuver ; the carotid artery required ligation .
the patient died 10 days postoperatively due to ischemic brain injury , diencephalic injury , and intractable increased intracranial pressure with brainstem herniation .
. most reports are by pens , knives , or chopsticks . due to its thin wall ,
the orbit is the most vulnerable structure in the cranium ; penetrating orbital injuries are often associated with traumatic brain injury .
the cranium can be violated via the transorbital route through the superior orbital fissure and optic canal .
the degree of neurologic damage is related to orbital bone anatomy , as well as the size , shape , and trajectory of the object .
intracranial penetration may occur through the orbital roof , superior orbital fissure or optic canal .
therefore , medial or canthal injuries , associated with severe visual loss , strongly suggest optic canal damage .
the most frequent site of penetration is through the orbital roof because the superior orbital plate of the frontal bone is thin and fragile .
this frequently leads to frontal lobe contusion , the prognosis of which is fairly good .
objects passing through the superior orbital fissure tend to follow a trajectory , close to the internal carotid artery and are generally associated with optic nerve and other orbital injuries .
the orbit is pyramid - like in volume , and as a result , penetrating objects are directed towards the apex , most of which pass through the superior orbital fissure and through optic canal .
our case is an example of this type of injury . penetrating injuries through the superior orbital fissure may affect cranial nerves iii , iv , v , vi , the arteries of the circle of willis and the carotid artery .
penetrating injuries caused by high speed objects , following a trajectory perpendicular to the orbital wall , result in direct bone fractures .
vertically directed objects may pierce the orbital roof and cause damage in the frontal lobe . horizontally penetrating objects may cause ethmoid bone or posterior orbital wall fractures . with sufficient force ,
the midline may be violated and can damage contralateral structures . penetrating objects , directed medially through the superior orbital fissure , the optic canal , and / or sphenoid wing , may damage the temporal lobe , cavernous sinus , and brain stem .
the most frequent pattern of injury ( 68% ) involves the cavernous sinus , temporal lobe , and brainstem . in low velocity injuries ,
when the penetrating object hits the orbit at a small angle , the object follows a path along the wall of the orbit .
penetrating objects , entering the orbit close to the horizontal plane , tend to follow the orbital funnel towards the apex .
this mechanism differs from that seen in orbital roof penetration , in which objects traverse the superior orbital fissure and pass laterally along the cavernous sinus toward the temporal lobe . in our case ,
the iron bar penetrated the orbit at the medial canthus and followed a posterior , medial , and superior trajectory .
objects directed superiomedially within the orbit usually affect the superior orbital fissure and / or optic canal , sphenoid wing , and sella turcica , passing across the midline ; then , they enter the suprasellar cistern and third ventricle , causing serious damage to neurovascular structures .
these types of injuries are associated with the most severe brain damage , due to laceration of central diencephalic neural structures and major vessels ; therefore , they are associated with the highest morbidity and mortality rates .
the injury described in this report usually has a fatal prognosis . in penetrating orbitocranial injuries
, the severity of brain damage and outcome depends on the velocity , trajectory , and shape of the object , rather than the type of material .
however , porous objects that are prone to fragmentation provide a good medium for infection . immediate complications of transorbital penetrating trauma include intracerebral hematoma , cerebral contusion , intraventricular hemorrhage , pneumocephalus , cranial nerve damage , severe permanent neurological damage , brain stem injury and cerebrovascular injury .
delayed complications include cerebrospinal fluid fistula , pneumocephalus , orbital cellulitis , carotid - cavernous sinus fistula , central nervous system infections , traumatic aneurysm and delayed intracranial hemorrhage .
retained foreign objects cause severe infections , such as meningitis or brain abscess ( 50% ) .
the prognosis is good in absence of direct injury to the brainstem or laceration of major intradural vessels . in our patient ,
ct is necessary to evaluate the trajectory of the object , the intracranial structures involved and to predict possible complications .
however , wooden objects are not always detectable on plain radiographs , making accurate evaluation more difficult .
if the injury is caused by a chopstick , and if chopstick is removed before the patient is evaluated by a physician , potentially fatal complications can occur .
magnetic resonance imaging ( mri ) is superior to ct for detection of small fragments of wooden foreign bodies .
therefore , cerebral angiography should be performed 2 - 3 weeks after an insult to rule out traumatic aneurysms and to identify major vascular injury in a timely fashion .
the transorbital or transcranial approach can be chosen depending on the location of the foreign body .
removal of the foreign object , debridement and resection of all involved skull bones , hematoma evacuation , careful hemostasis along the trajectory , and meticulous dural closure to reduce cerebrospinal fluid leak are mandatory to prevent potentially fatal infectious complications .
vigorous debridement is not necessary and is associated with an increased disability and mortality without clear advantage .
antiepileptic medications are recommended in the early stages after injury to prevent seizures . in conclusion ,
transorbital penetrating cranial injury by a metal bar is rare and may result in potentially life - threatening complications .
failure to detect intracranial complications may lead to serious neurological morbidity and is associated with a high mortality rate .
 transorbital intracranial injury is uncommon , representing 0.04% of penetrating head trauma with a high mortality rate . 
 orbital penetrating injuries may cause severe brain injury if the cranium is entered , typically via the orbital roof , the superior orbital fissure , or the optic canal . 
 a 13-year - old male sustained a severe brain injury due to penetration of the right orbit with an iron bar . 
 the bar entered the inferiomedial aspect of the orbit and emerged from the left occipital bone . 
 neurological examination revealed deep coma ( gcs : e1m2v1 ) with fixed , dilated , and non - reactive pupils . 
 the bar followed an intracranial trajectory , through the third ventricle and suprasellar cistern . 
 the patient underwent an immediate exploration with removal of the bar . 
 unfortunately , he died 10 days postoperatively due to severe diencephalic injury with brainstem herniation . in this case report 
 , we discuss the radiologic diagnosis and surgical management of transorbital orbitocranial injury by foreign body penetration . 
Introduction
Case Report
Discussion