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During the past 5 years of Operation Iraqi Freedom (OIF), a significant majority of the severe closed and penetrating head trauma has presented for definitive care at the National Naval Medical Center (NNMC) in Bethesda, MD, and at the Walter Reed Army Medical Center (WRAMC) in Washington, DC. The purpose of this article is to review our experience with this population of patients.A retrospective review of all inpatient admissions from OIF was performed during a 5-year period (April 2003 to April 2008). Criteria for inclusion in this study included either a closed or penetrating head trauma suffered during combat operations in Iraq who subsequently received a neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all patients for whom primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow coma scale (GCS) and injury severity score at admission, and Glasgow outcome scale (GOS) at discharge, 6 months, and 1 to 2 years.Five hundred thirteen consultations were performed by the neurosurgery service on the aforementioned population. Four hundred eight patients met the inclusion criteria for this study (401:7, male: female; 228 penetrating brain injury, 139 closed head injury, 41 not specified). Explosive blast injury (229 patients; 56%) constituted the predominant mechanism of injury. The rates of pulmonary embolism (7%), cerebrospinal fluid leak (8.6%), meningitis (9.1%), spinal cord or column injury (9.8%), and cerebrovascular injury (27%) were characterized. Cerebrospinal fluid leak, vasospasm, penetrating head injury, and lower presenting GCS were statistically associated with longer intensive care unit stays and higher presenting injury severity scores (p < 0.05). While presenting GCS 3–5 correlated with worsened short-term and long-term GOS scores (p < 0.001), almost half of these patients achieved GOS ≥3 at 1- to 2-year follow-up. Total mortality after reaching NNMC/WRAMC was 4.4%.OIF has resulted in the highest concentration of severe closed and penetrating head trauma to return to NNMC and WRAMC since the Vietnam Conflict. Management scenarios were complex, incorporating principles designed to maximize outcomes in all body systems. Meaningful survival can potentially be achieved in a subset of patients with presenting GCS ≤5.