Cranio-orbital injury with internal carotid artery laceration and a missing eyelid

A 37-year-old man presented to the emergency department with a visor impacted in the left orbit after a motorbike accident. His initial injury appeared to be limited to the orbit. Because the bleeding appeared disproportionate to the orbital injury, an intracranial injury was suspected. Subsequently, on hemicraniotomy, the tip of the visor was found at the bifurcation of the internal carotid artery. The avulsed upper eyelid was found under the frontal lobe. The patient underwent the clipping of internal carotid artery and middle and anterior cerebral artery with replantation of the upper eyelid. Neurologic damage was limited to loss of vision, right foot drop, and bowel and bladder incontinence. This case of penetrating orbital trauma demonstrates that the absence of focal neurologic deficit and radiologic signs suggestive of intracranial injury may not rule out life-threatening intracranial injury.