Patients who have penetrating head injury all too often present with some of the most devastating and challenging intracranial injuries. The mechanisms of injury and associated neuropathology affect every body system and require a multidisciplinary approach. Evidence-based guidelines have been developed to offer some direction to clinicians involved in their care. Much remains scientifically unsubstantiated, however. Optimal management of critically ill patients who have penetrating head injury requires clinical expertise and care of the highest quality.