Patients with clinical brain death following head injury are important potential cadaveric organ donors. We analyzed our series of cranial gunshot wounds with particular attention to the frequency and patterns of organ donation after fatal injuries. Sixty-six patients with gunshot wounds to the head, including 59 with intracranial involvement (43 male, average age 26 years) were seen during a 4-year period. Injuries were limited to the head in 50 of 59 patients. Overall mortality was 66 per cent. Predictors of mortality included Glasgow Coma Scale (GCS) of six or less (93%), self-inflicted gunshot wounds (75%), and computed tomography (CT) findings of bihemispheric injury (87%) or ventricular injury (82%). Of the 39 patients who died, 28 met standard criteria for brain death, and nine of these went on to organ procurement. Thirteen families refused donation, and six patients were not harvested for reasons including old age, pregnancy, suspicion of AIDS, coroner refusal, and failure to pursue consent. Principles essential to maximal organ retrieval include: 1) Recognition that patients suffering cerebral gunshot wounds represent potential organ donors and that certain factors are predictive of mortality; 2) Critical care/trauma team approach with standardized management and timely declaration of brain death; 3) Early search for family members and prompt notification of organ procurement agencies; 4) Sensitivity to cultural issues influencing donation; and 5) Programs to increase public awareness of organ donation.