Traumatic brain injury (TBI) remains a major cause of death and disability worldwide, and missile-induced TBI remains the most deadly of all traumas since first reported and has always been associated with high mortality and morbidity. The prevalence of TBI secondary to gunshots is strikingly variable and reflects the global scenery of violence. Injuries from gunshot wounds (GSW) to the head place an extreme economic burden on the public while disabling the victims in the zenith of their life and imposing enormous medical, legal, and emotional costs. Since every gun/projectile combination is associated with a typical pattern of injury, war injuries differ significantly from others. We will focus here on predominantly penetrating civilian gunshot wounds with low muzzle velocity (<1,000 f/s) as they occur in the setting of homicide and suicide attempts or during accidents. Many surgeons did take patients to the OR over the last 30 years, and they have achieved a remarkable reduction in morbidity from well above 50 % to less than 25 % in patients admitted with severe brain injury. However, in the setting of increasingly limited resources, recent research focus has shifted toward more precise prediction of survival as well as on better functional outcome.