An 18-year-old man was injured by a gunshot wound to the head. He was stabilized in the emergency department and underwent emergency craniotomy, with induced coma for the first 2 days postsurgery. He demonstrated no responsiveness under sedation on day 3, but within 24 hours improved to sustained alertness and could follow commands. He was able to walk without assistive devices and regained full orientation by 7.5 weeks. However, he remained passive, unconcerned with his situation, and predominantly spent his time watching television with irritability whenever interrupted. He required prompts to initiate necessary activities of daily living such as dressing and showering. He was able to learn new information but had poor judgment and problem-solving abilities. He displayed little inhibition when consuming food, new from before the injury. At 13 months post­injury, he was arrested for weapon possession during an outing with friends. In the years to follow, he returned home with the ability to maintain household independence but became paranoid with obsessive-compulsive disorder-like tendencies and a need to constantly check the security features of his residence.

Head CT showed bifrontal bone defects corresponding to entry and exit wounds, with edema and shrapnel traversing the frontal lobes ( Fig. 64.1 ).

Penetrating gunshot injury. Head CT shows bifrontal bone defects corresponding to entry and exit wounds, with edema and shrapnel traversing the frontal lobes ( arrows ). There are bilateral decompressive craniotomies associated with subgaleal fluid collections.

Patients with penetrating head trauma can present with superimposed hypoxic-ischemic encephalopathy, seizures, medication effects, and vascular complications.

Skull fractures can occur with both blunt and penetrating head trauma.

Cerebral edema may be associated with hypoxic-ischemic brain injury and acute inflammatory and autoimmune processes.

Brain parenchymal tracts can be seen with penetrating trauma and neurosurgical interventions.