We report results of a survey on the management patterns of penetrating head injury (PHI). American neurosurgeons (N = 2969) were asked to participate in a mail survey. One thousand one hundred twenty-eight responded, providing detailed information about their practices, their opinions concerning diagnostic testing, nonoperative therapy, and surgical debridement for PHI. Although there was agreement on some areas of management and care, including the use of computed tomography scanning, antibiotics, anticonvulsants, and a few surgical indications/contraindications, there was wide variation on a significant number of points. These included testing for coagulopathy; use of corticosteroids, intracranial pressure monitoring, and barbiturate coma; and surgical indications including debridement of contusions, removal of fragments, location of injury, and Glasgow Coma Score 5-8. Many nonoperative decisions were influenced by the presence of neurosurgical residents, whereas the decision to operate was based primarily on judgment of patient salvageability. This survey uncovered disagreement on several crucial issues in the care of patients with penetrating head injury and the need for continued research in this area of patient care.