Objective: We aimed to analyze the penetrating war head injuries in sieged Sarajevo during the first part of Bosnian war and to present our operative strategies in treatment of patients. Method and patients: We conducted a retrospective study of injured patients in sieged Sarajevo during the first two years of the Bosnian war (April 1992-July 1994) using a review of the hospital data. Our typical surgical strategy was craniectomy with reduced debridement of the brain injury without search and removal of the deep intracranial foreign fragments. In 34% of cases, operation was performed based only on clinical examination due to lack of electricity in the sieged city. Results: A total of 1,728 neurosurgical injured patients were admitted to our department from the region of central Sarajevo (361,179 inhabitants) with an almost equal divide of civilians and military personnel. Eighty-four percent of patients were admitted within 3 hours of injury and operated without any delay. Diagnosis was largely dependent on clinical examination (35% of cases) and plain radiography (47%). Computed tomography scan was only used 18% of the time due to lack of availability. The majority of neurosurgical injuries were head injuries (80%). Spine injuries comprised only 6% patients and peripheral nerve injuries 14%. Over 80% of head-injured patients had a penetrating injury. The patients with head injuries were operated on in 70% of the cases. Mortality of patients that were operated on with head injuries was 13.3%. The number of severely brain-injured patients with Glascow Coma Scale (GCS) 3 and GCS 4 who died were 143 (35%) and 122 (30%) respectively, giving a total of 265. The GCS 4 patients were operated on only in the case that compressive intracranial haematomas had been detected. A total mortality of the patients with head injury was 30%. Over 60% of injured patients who died were under 50 years old. The most common cause of death were excessive penetrating brain injury (85%) caused by high velocity missiles. Metal grenade fragments were the cause of injury in 73% of cases. Good outcome without any focal neurological deficit was found in 42.6% of all patients with head injuries. Conclusion: Our noninvasive early neurosurgical operative approach in the form of intracranial haematomas evacuation and reduced brain debridment without search for deep intracranial foreign bodies resulted in an acceptable treatment outcome during the Bosnian war.