Transorbital impalement injury with massive intracranial lesion not detected by cranial CT scan.

An extraordinary case of transorbital penetration injury is presented. A 24-year-old male patient was involved in a fight and was pushed against a shelf. He immediately lost consciousness and was brought to hospital. A cranial computed tomogaphy (CT) scan showed a hemorrhage and brain edema over the left hemisphere with orbital roof fracture. A decompressive craniectomy was performed. Intraoperatively, an orbital roof fracture with penetration of the frontobasal dura could be seen which could not be explained by the trauma mechanism. The postoperative magnetic resonance imaging (MRI) with susceptibility-weighted image (SWI) showed two injury tracks from the orbit through the brain which appeared to be penetration injuries. The forensics department was consulted and penetration by a falling candleholder was found to be the cause of the injuries. In this case, the cranial CT alone did not show any indication of a penetration injury. Only MRI revealed the penetration track, which stresses the diagnostic value of this modality and especially the SWI in cases where the trauma mechanism does not correspond to the injury shown in the CT scan.