Cranial gun shot injuries

Cranial gun shot injuries are a form of penetrating traumatic brain injuries, which are much less common than blunt traumatic brain injuries. 

Incidence of gun shot injuries to the head is increasing in some countries, due to the ease of accessibility of firearms. In the civilian population, suicide and criminal activity account for the majority of cases and young male adults remain the most at risk 4.

There are five major gun shot injuries of the head 4:

  1. penetrating: entry wound with no exit would
  2. perforating: entry and exit wound with tract through the brain parenchyma
  3. tangenital: strikes the head obliquely without penetrating the brain parenchyma but may result in scalp injury, skull fractures or parenchymal contusions
  4. ricochet: penetrating projectile that bounces off the inner table of the skull
  5. careening: penetrates the skull and travels with its trajectory external to the parenchyma potentially injuring the dural venous sinuses

Please see the main article "imaging of gun shot injuries" for a general description of imaging features. 


The entry and exit wounds can be identified paying attention to the bone “beveling”. An inward beveling of the inner skull table is supportive of the entry wound, whereas the outward beveling of outer skull table suggests the exit wound. Often there is not an exit wound, especially in incomplete metal jacket bullets (e.g. hollow point tip) that are designed to fragment and lose kinetic energy along their path 1

CT angiography

Angiographic imaging is used when there is evidence or high suspicion of intracranial vascular injury. Projectiles in or having traversed the base of skull have a high incidence of vascular injury 4. CTA may demonstrate a CTA spot sign indicating active haemorrhage at the time of the scan, as seen in non traumatic intraparenchymal haemorrhage, which correlates with a worse prognosis. Vascular injuries include be transection, pseudoaneurysm, dissection or thromboembolic occlusion.

Digital subtraction angiography

DSA is used when CTA fails to demonstrate a vascular injury and the suspicion remains high or endovascular treatment is being considered. Delayed DSA may also be performed to assess for complications such as AV fistula 4.

Unsurprisingly, mortality is high. In civilian shootings, approximately 20% survive the initial injury, and of those ~50% (range 30-68%) survive 2

There are numerous complications ranging from instant to delayed 4:

  • infection
  • CSF leak
  • vascular injury
  • infarct
  • hydrocephalus
  • dural venous sinus thrombosis
  • bullet migration

Share article

Article information

rID: 41967
Section: Gamuts
Synonyms or Alternate Spellings:
  • Gun shot injury to the head
  • Gunshot injury to the head
  • Cranial gunshot injury

Support Radiopaedia and see fewer ads

Cases and figures

  • Drag
    Case 1
    Drag here to reorder.
  • Drag
    Case 2
    Drag here to reorder.
  • Drag
    Case 3
    Drag here to reorder.
  • Drag
    Case 4
    Drag here to reorder.
  • Drag
    Case 5: old cranial gunshot injury
    Drag here to reorder.
  • Drag
    Case 6: bullet in orbit
    Drag here to reorder.
  • Updating… Please wait.

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.