Bedside Cranial Ultrasonography in Patients with Hemicraniectomies: A Novel Window into Pathology

NCJ_cover.jpgBy Vasisht Srinivasan, Matthew Smith, Jordan Bonomo

First Online: 11 April 2019

Point-of-care ultrasound (POCUS) use has grown considerably recently. Inadequate windows have limited adult cranial ultrasound to transcranial Doppler and optic nerve sheath measurements, but hemicraniectomy provides an obvious, underutilized window for intracranial imaging. We describe the novel use of POCUS to monitor postoperative subdural collections and midline shift.

Serial POCUS images were obtained from a hemicraniectomy patient and compared with near-concomitant computed tomography (CT) scans. The University of Cincinnati hemicraniectomy preset was created and optimized using a broadband sector array transducer with a 4–2 MHz operating frequency range. The depth and focus were set to visualize the brain tissue and contralateral bone. Imaging parameters were tested and saved for 2D grayscale mode, with an emphasis on tissue harmonic imaging, adaptive image processing, and dynamic range.

Patient Case
A 37-year-old man presented to a regional Level I trauma center with an initial Glasgow Coma Score of 8 (E1V2M5) and index non-contrast head CT revealing bifrontal contusions, a left temporal subdural hematoma, and 3 mm of shift. Repeat imaging revealed worsening edema and uncal herniation, prompting an emergent left hemicraniectomy. A postoperative right temporal hygroma was found on surveillance CT (Fig. 1a) that correlated with contemporaneous POCUS imaging (Fig. 1b). Neurologic decline prompted repeat imaging demonstrating hygroma expansion on POCUS, confirmed on CT (Fig. 1d, e). The patient underwent drainage with subsequent examination improvement.

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