AN AGGRESSIVE SURGICAL strategy was applied to cranial gunshot wound victims at Cook County Hospital in Chicago from 1983 to 1992. A series of 480 patients with an overall mortality rate of 34% is presented. A total of 150 patients underwent craniotomy with an operative mortality rate of 21%. Criteria for operation were Glasgow Coma Scale scores of 3 through 7 without hypotension or fixed and dilated pupils or Glasgow Coma Scale scores of 8 through 15 with intracranial bone fragments or significant clot. This study supports previous reports that even patients with severe neurological deficits and massive cerebral damage can benefit from aggressive treatment and make satisfactory recoveries.