Fatal Russian roulette refers to death following an act of extreme bravado in which the individual spins the cylinder of a revolver loaded with at least one cartridge, aims the muzzle at the head, and pulls the trigger. The majority of victims are men younger than 30 years who, in the presence of others, are under the influence of ethanol or other drugs. This is a 10-year (1993-2002) retrospective review of self-inflicted gunshot wounds of the head, among which we culled and paid special attention to cases of Russian roulette, at the Medical Examiners' Offices in Kentucky. Of the 24 incidents of Russian roulette, the majority of victims were white (79.2%), and all were men between 14 and 47 years with a mean age of 24.8 years. Compared with other cephalic firearm suicides, the subjects engaging in Russian roulette were significantly more likely to have elevated blood levels (> or = 0.1%) of ethanol along with various drugs detected in urine. Although the presumed intent of the risky act is to survive, Russian roulette is deemed to be suicide, which is based on a comprehensive understanding of the inherently deliberate, volitional actions of the decedent.