The records of 82 patients with penetrating gunshot wounds of the head seen during a 2-year period (1973 through 1975) were reviewed. All patients had a thorough neurologic evaluation and diagnostic roentgenographic studies within 5 hours of injury. The state of consciousness, which could be assessed by simplified neurologic examination, emerged as the key parameter in prognosis; no patient seen within 5 hours after injury with decorticate or decerebrate posture survived. Anteroposterior, lateral, and the base view X-rays were of great help in differentiating between extra- and intracerebral location of the bullet. The best combination of diagnostic studies are the skull series and the CT scan. Surgery was performed on 45 patients, and 31 of these achieved functionally satisfactory results. The primary purpose of the surgery was for debridement and only in few cases for removal of a mass lesion. Antibiotic infection prevention was effective in all but two patients, who developed postoperative meningitis; none developed a brain abscess. The incidence of hematomas in surgical and autopsied patients was 10%. Simple grading criteria emerged that allow prognostication at admission of both survival and its quality. We conclude that less severely injured patients should be operated on within 3 to 8 hours and patients who are comatose and nonresponsive at admission should receive primarily supportive treatment, with surgery undertaken only if significant intracranial blood clot is seen on CT scan.