Gunshot wounds to the head are often associated with poor outcome. It has been repeatedly shown that outcome correlates closely with (1) mechanism of injury, (2) time to resuscitation, (3) coexistence of systemic injury, (4) presenting Glasgow Coma Scale (GCS) score, (4) pattern of pupillary reaction, (5) imaging assessment of injury (extent of damage and bullet trajectory), (6) systemic coagulopathy, and (6) the development of diabetes insipidus (Kim et al., Neurosurgery 57(4):737–747). The best prognosis is carried for the patients admitted with a GCS > 8 and only supratentorial unilobar injury, the worst prognosis is for patients with bilateral transventricular injuries with a central trajectory.However, some patients will have good functional outcome despite a bad injury. If you do intervene, act as fast and as aggressively as possible. Obtain a CT scan ASAP to make a decision on whether operative intervention is indicated. If in doubt, take it out!