In penetrating injury from high-velocity missiles, injuries may occur not only from initial laceration and crushing of brain tissue by the projectile but also from the subsequent cavitation. High-velocity objects create rotations and can create a shock wave that cause stretch injuries, forming a cavity that is three to four times greater in diameter than the missile itself. A pulsating temporary cavity is also formed by a high-speed missile and can have a diameter thirty times greater than that of the missile. Though this cavity is reduced in size once the force is over, the tissue that was compressed during cavitation remains injured. Destroyed brain tissue may either be ejected from entrance or exit wounds or packed up against the sides of the cavity formed by the missile.
Low-velocity objects usually cause penetrating injuries in the regions of the skull's temporal bones or orbital surfaces, where the bones are thinner and thus more likely to break. Damage from lower-velocity penetrating injuries is restricted to the tract of the stab wound, because the lower-velocity object does not create as much cavitation. However, low-velocity penetrating objects such as slow bullets may ricochet inside the skull, continuing to cause damage until they stop moving.
Studies with PET scanning and transcranial Doppler imaging have shown that changes in cerebral blood flow, such as hypoperfusion and vasospasm, can follow penetrating head injury. These changes can last for two weeks. An ischemic cascade similar to the course of cellular and metabolic events that follow other head injuries may follow penetrating head injuries. Sometimes in penetrating injuries, the brain releases thromboplastin, which can lead to problems with blood clotting.
While blunt head trauma does not present a risk of shock due to hemorrhage, penetrating head trauma does.
Surgery may be required to debride or repair the injury or to relieve excessive intracranial pressure. Intracranial pressure is monitored and attempts are made to maintain it within normal ranges. Intravenous fluids are given and efforts are taken to maintain high blood oxygen levels.
Penetrating head trauma can cause loss of abilities controlled by parts of the brain that are damaged. A famous case was that of Phineas Gage, whose personality may have changed after a penetrating injury to his frontal lobe(s).
People with penetrating head trauma may have complications such as acute respiratory distress syndrome, disseminated intravascular coagulation, and neurogenic pulmonary edema. Up to 50% of patients with penetrating brain injuries get late-onset post-traumatic epilepsy.