1. Background and Importance
Orbitocranial injuries are rare and generally presented with severe brain damage [1]. This type of brain injury represents 0.04% of all traumatic brain injuries—24% of open head injury in adults [2]. A multitude of foreign bodies can injure the brain by passing through the orbit. Depending on the direction of the trauma, a foreign body can reach the brain either through the orbital roof, the superior orbital fissure, or the optic canal [3]. The diagnosis is confirmed in most cases when the foreign body is found in the wound or by x-ray imaging [4, 5, 6, 7, 8]. In this case report of a penetrating brain injury by a knife through the medial aspect of the orbit, we reviewed the radiological findings and surgical management.

2. Case Presentation 
A 33-year-old man was admitted to the Emergency Department because a knife got stuck in the medial region of his right eye (Figure 1). He felt severe pain in the eye, which became excruciating when attempting to move the eye.
On examination, the knife appeared to be embedded in the globe, with slight bleeding. He had an ecchymosis of the eyelids with a red eye and edematous conjunctiva. The left eye and neurological examination were normal. The globe was intact, the pupil nonreactive with some subconjunctival hemorrhage. Laboratory examinations were normal. He was given intravenous antibiotics and a tetanus booster. The eye was bandaged with gauze, and the patient was transferred to perform a radiological examination. Plain skull radiographs confirmed the intracranial place of the knife through the orbital roof (Figure 2). Computed tomography of the head and face without administration of the contrast material was recommended, and the result showed a 7-cm knife inside the right orbit near the medial canthus, transversing the orbital plate of the frontal bone passing through the right frontal lobe near the frontal horn of ipsilateral ventricle without intraparenchymal hemorrhage or intraventricular inundation (Figure 3). Cerebral angiography was not performed since it is not available in our department. Moreover, we did not perform it unless the foreign body passes near a sizeable arterial trunk such as the sellar region, Sylvian fissure, or interhemispheric area [5, 6]. We preferred to manage the closure of the dura defect conservatively because of the damage caused by the approach [5].
In our case, the wound was linear far from LCR lacs and could be patched by the gravitational effect of the brain and arachnoid on the one side and the periorbital and orbital fat on the other side. We brought the patient into the operating room, where the trachea was intubated after general anesthesia. After preparing a pterional approach, we manually extracted the knife taking care not to injure further the contents of the orbit (Figure 4).

After several minutes without evidence of external or intracranial bleeding or any change in the patient’s vital signs, we concluded the extraction was completed without complication. 
Exploration after extraction found scleral and a lower eyelid wound which an ophthalmologist sutured. Follow-up CT demonstrated no intracranial hemorrhage.
The prognosis was excellent by a spectacular improvement in visual acuity and no neurological or oculomotor deficit. The patient was given antibiotics and eye drops. The long-term outcome was without neuro-ophthalmic sequelae with a very satisfactory aesthetic result (Figure 5). 3. Discussion
Penetrating orbitocranial injuries are rare, but they have significant morbidity and mortality (up to 30%) [1, 4].
Transorbitocranial stab wounds have a higher incidence of vascular and brain injuries and severe infectious complications [3, 4, 5, 6, 7, 8, 9]. The most frequent penetration site is through the orbital plate frontal bone, which is highly vulnerable due to its low thickness. This condition explains the high frequency of frontal lobe contusions, which its prognosis is relatively good [3]. 
Orbitocranial injuries are explored by craniofacial CT scan. It allows pinpointing lesions caused by penetrating trauma. CT scan determines location and direction of foreign bodies, especially if there is any associated lesion such as calvarial fracture with bone fragments and/or hematoma. It can also help planning surgery to avoid complications. The severity of lesions should be determined as soon as possible as it can identify the lesion extension. Any retained foreign body, location, and inward driven bone fragments that determine the penetrating track, hematoma, and other associated lesions provide helpful information for the planning of the surgical procedure [7, 9].
Immediate complications include globe rupture, retinal detachment, extraocular muscle injury, or optic nerve avulsion. Other complications must be searched as intraventricular pneumocephalus, intraventricular hemorrhage, vascular injury, or brain stem contusion [4].
After eliminating a vascular compromise and foreign bodies far from vital structures, we can remove the foreign body without dissection. 
To obtain a good outcome, it is essential to perform an urgent CT scan to guide an immediate surgery, determine all the lesions for planning extraction of foreign bodies and intervene for any associated urgent situation that can cause the patient’s death. Post-operative antibiotics and intensive care avoid immediate complications and help with prognosis [4, 5, 6, 7, 8, 9]. 

4. Conclusion
Penetrating orbitocranial trauma by a sharp object is rare. Several lesions can affect the functionality and prognosis. The diagnosis is based on clinical examination and radiological imaging. Urgent multidisciplinary management is mandatory for an excellent therapeutic evaluation. Intracerebral hemorrhage remains a serious complication that can result in life-threatening or significant morbidity.


Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article. The participant was informed about the purpose of the research and its implementation stages. Written informed consent was obtained from the patient.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conception and design: Youssef Fahde; Data Collection: Youssef Fahde; Data Analysis and Interpretation: Youssef Fahde, Davis Mpando; Drafting the article: Youssef Fahde, Davis Mpando; Critically revising the article: Mehdi Laghmari, Houssine Ghannane, Said Ait Benali; Reviewing submitted version of manuscript and approving the final version of the manuscript: All authors. 

Conflict of interest
The authors declared no conflict of interest.

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