Cranial gunshot wounds frequently produce devastating injuries to central nervous system (CNS) structures. Surgical therapy and primary and secondary debridement, including repair of dural defects and removal of retained intracranial bone and metal fragments, were applied to 374 cranial gunshot wound victims at Gulhane Military Medical School in Turkey from 1992 to 1999. Dural defects were closed primarily or with temporalis fascia, pericranium, and cadaver grafts. Central nervous system infections were mostly observed in cases with cerebrospinal fluid (CSF) fistulas. All patients underwent computed tomography (CT) scans periodically. In 119 of 374 (32%) patients, bone and metal fragments were determined on control CT scans. We also performed angiography in some patients to reveal traumatic vascular pathologic findings. Most of the deaths in this group of patients were attributed to the direct effects of brain injury and occurred within the first month after injury. Fragments retained after the first debridement were followed periodically by CT scan. Surgery was not performed until infection developed. Retained fragments did not increase the infection risk, but high rates of infection did occur in cases with CSF fistulas. The presence of diffuse brain damage, brainstem injury, CNS infection, or ventricular injury was associated with a poor outcome.