Background: Penetrating orbital injuries constitute a significant threat to ocular and cerebral structures. The incidence of central nervous system damage from orbital injury is related to the orbital anatomy and the characteristics of the penetrating object. Penetrating orbital injuries involving the brain stem are extremely rare. Objectives: To present an uncommon case of penetrating orbital injury and to discuss surgical management. Case study: A patient suffered from a penetrating injury by a Bakelite comb which extended from his left orbit through the cavernous sinus to the pons. Complete occlusion of the left cavernous segment of the internal carotid artery was detected and a frontotemporal craniotomy with lateral superior orbitotomy was performed to remove the object. A delayed asymptomatic carotid-cavernous fistula was identified 1 year later. Conclusion: Surgical treatment remains the mainstay of intervention for penetrating orbitocranial injuries. The rationale of surgical removal of a foreign body should focus on safe exposure and removal of the object at the earliest without inflicting further injuries. Close follow-up for a delayed carotid-cavernous fistula is necessary.