Background <p>Penetrating injuries to the posterior cranial fossa are extremely rare. Perforating skull injuries are also not frequently recorded, with only ten cases reported in the literature. Combining these two factors, this case report presents a patient with a perforating head injury at the posterior cranial fossa caused by an iron rod and shares the clinical management of this rare case.</p> Case presentation <p>An 18-year-old Vietnamese male construction worker was admitted following a 3-m fall from scaffolding due to an occupational accident. Upon admission, the patient was conscious, hemodynamically stable, and no neurological deficits or other associated injuries were detected. A 1-m-long, 0.8-cm-diameter iron rod had penetrated from the left neck to the right occipital region. Owing to the size of the foreign body, only an X-ray was performed. The patient underwent emergency surgery to remove the foreign object and manage the damaged brain tissue. Intraoperatively, a contusion of the right cerebellar hemisphere with a complex dural tear, subarachnoid hemorrhage, and multiple small metallic fragments was found, with no spinal cord or major vessel injuries. Postoperatively, the patient recovered well. After 3&#xa0;years of follow-up, the patient had excellent results and returned to normal daily activities.</p> Conclusions <p>The optimal surgical approach should be carefully planned, especially in cases where preoperative computed tomography imaging is challenging. It is recommended to plan the direction of foreign body extraction and limit the use of artificial materials.</p>