Background: Penetrating head injury secondary to crossbows is a rare encounter in neurosurgical practice with only few cases reported in the literature. Methods: Chart review and literature review. Results: A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow he bought from a department store. The patient arrived neurologically intact. He was not able to verbalize due to jaw fixation with the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavities, along with the palate and the skull base, and the left frontal lobe were all breached (figure). No vascular injury was identified on imaging (figure). The arrow was surgically removed in the operating room after establishing an elective surgical airway. A planned delayed CSF leak repair was performed. The patient made a substantial recovery and was discharged home in good status. Conclusions: - Multidisciplinary team is key.

Vascular imaging should be done pre and post-intervention.

Surgical approach is determined by the trajectory.

Psychiatric illness and access to weapons are major risk factors.

Elective surgical airway might be indicated.