Identification of intracranial hemorrhage progression by transcranial point-of-care ultrasound in a patient with prior hemicraniectomy: a case report

Abstract

Transcranial ultrasound has been described as a tool to identify intracranial pathology, however, it is seldom used in the adult patient population due to poor imaging windows and rapid availability of more advanced imaging such as CT and MRI. We report a unique population in which transcranial ultrasound may be beneficial: those with a history of hemicraniectomy. We present a case of a 65-year-old male with a history of hemicraniectomy who suffered head trauma after a fall from his wheelchair. An initial non-contrast head CT scan identified an intracranial hemorrhage. Point-of-care bedside transcranial ultrasound was able to identify the progression of intracranial hemorrhage, which was confirmed by interval head CT. This prompted repeat CT imaging followed by neurosurgical intervention with the placement of an external ventricular drain in the right lateral ventricle. While ultrasound is unlikely to replace the need for more advanced imaging in these patients, point-of-care transcranial ultrasound may be a useful tool that can be employed rapidly at the bedside for interval screening in patients with hemicraniectomy and concern for new or worsening intracranial hemorrhage.

Keywords: Bleeding; Hemorrhage; Intracranial; Point-of-Care; Transcranial; Ultrasound.

Fig. 1

a Axial image of initial head CT showing right sided intracranial bleed with intraventricular blood products (*). b Axial image from Point-of-care ultrasound performed 2 h after initial CT, showing large volume hyperechoic material representing blood (*) within right lateral ventricle, increased from prior CT. c Axial image from repeat head CT, performed 6 h after initial CT, showing worsened intracranial bleeding from with intraventricular extension (*), similar to prior ultrasound findings