BACKGROUND Craniocerebral missile injuries have steadily increased to become the most common form of penetrating neurotrauma in our environment resulting in continued morbidity and neuropsychological sequelae. Civilian infratentorial gunshot injuries are uncommon but generally regarded as fatal injuries, with many patients dying before reaching hospital. METHODS A retrospective analysis of 1,069 patients with civilian gunshot wounds (GSW), admitted to our unit over a 14-year period (1986-2000), identified 26 patients with infratentorial gunshot injuries (2.4%). A detailed analysis of these patients was carried out, which included demographic factors, clinical and anatomic correlation, computed tomography scans, surgical management, and outcome. RESULTS All patients were male. The mean age was 26.5 +/- 11.5 years and the mean admission Glasgow Coma Score 11.8 +/- 2.7. Twenty-four of 26 patients required cerebrospinal fluid (CSF) diversion to control secondary hydrocephalus. The second commonest surgical procedure was posterior fossa decompression. Five of 26 patients died (19.2%). Severe morbidity was noted in 9 of 21 surviving patients (42.8%). Significant predictors: good outcome was associated with primary missile entry of the infratentorial compartment (p = 0.005), while patients with supratentorial to infratentorial missile trajectory were noted to have a poorer outcome (p = 0.041). Location of cerebellar injury (lateral or medial) and missile caliber had no significant influence on patient outcome. CONCLUSIONS Early control of incipient or established hydrocephalus and aggressive surgical management where appropriate, with careful postoperative monitoring, is necessary for good outcome in patients with civilian infratentorial missile injuries.