Management of Transorbital Penetrating Intracranial Injury by a Homemade Metal Arrow: Serials Case Report

BACKGROUND: Transorbital penetrating intracranial injury (TOPI) is rare lesions, representing about 0.4% of traumatic brain injury. This uncommon injury has potentially severe and fatalities brain damage with high mortality rate if not promptly treated. CASE REPORT: We presented three patients with TOPI following penetration by a homemade metal arrow; unfortunately, two patients (cases 1 and 2) death on arrival at our hospital. As a survival patient (case 3), a 15-year-old boy presented with a homemade metal arrow entered through a right superior orbital fissure into the right cerebral hemisphere. Plain skull radiograph showed that the tip of the shaft was located in the right of the posterior cerebral hemisphere and confirmed by computerized tomography (CT) and three-dimensional CT of his brain. Injury to the right middle cerebral arteries was apparent on non-contrast CT angiography. Using a right occipital craniotomy approach with C-arm radiography fluoroscopy guidance, we successfully removed the arrow. Follow-up studies confirmed an excellent outcome. CONCLUSIONS: Pre-operative imaging is mandatory to evaluate the trajectory, brain, and vascular injury for appropriate surgical planning and post-operative care of patients with TOPI.