key: cord-0864411-h1hnzkr8 authors: Zakharchenko, Svetlana; Hansen, Allyson; Ibikunle, Aminat; Devasagayaraj, Richard; Charles, Patrick title: Intracranial hemorrhage detected through a craniotomy site with point of care ultrasound date: 2021-06-18 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12419 sha: ef134f9d8227362aece3c7a01c834b9d2246b212 doc_id: 864411 cord_uid: h1hnzkr8 A 60‐year‐old male presented to the emergency department with acute change in mental status while recovering from a recent hemicraniectomy. During evaluation by the emergency physician, a point‐of‐care ultrasound (POCUS) was performed using the patient's existing craniectomy site as a sonographic window. Multiple areas of intracranial hemorrhage were visualized on POCUS and head computed tomography scan ultimately requiring urgent neurosurgical intervention. Our case report demonstrates an innovative application of POCUS in the emergency department‐ setting that has potential to expedite diagnosis and management of life‐threatening neurosurgical etiologies, such as hemorrhage and midline shift, in a unique patient population. Decompressive hemicraniectomy is increasingly used for both therapeutic and prophylactic indications in traumatic brain injury and stroke and in the setting of space-occupying lesions. [1] [2] Several case reports in neurocritical care literature have suggested the use of transcranial ultrasound to monitor postoperative subdural collections and midline shift after hemicraniectomy. [3] [4] [5] [6] A positive correlation between computed tomography (CT) scans and transcranial ultrasound in assessing volumes of hyperdense lesions such as acute hemorrhage is reported in a number of small studies; this correlation is particularly good in the first 4-7 days from onset of hemorrhage. [7] [8] [9] However, no literature to date has cited use of point-of-care ultrasound (POCUS) by emergency medicine clinicians during initial evaluation of the patient using a craniectomy site for visualization of suspected hemorrhage. We describe such a case here. The examination was performed using a Mindray M9 device (Mindray, Nanshan, Shenzhen, China) with a C5-1s curved array (curvilin- intention to insonate more detailed images and provide further diagnostic detail. However, it proved to be ineffective likely owing to the lack of appropriate depth necessary to visualize the brain in its entirety (see Figure S1 ). Neither color nor spectral dopplers were used because shift was appreciated on this examination (see Figure 1 ). The entire procedure required ≈3 minutes to capture the necessary images/clips. The patient did not experience discomfort nor did the procedure delay his diagnostic evaluation or medical care. Neurosurgical and neurologic literature has described visualization of intracranial structures using TCUS through a thin part of the intact temporal bone located above the zygomatic arch. This sonographic "transtemporal window" has been used for identification of stroke, hydrocephalus, and space occupying lesions. 11 Caricato et al described a step-by-step approach to TCUS imaging and implied its usefulness and theoretical accuracy when craniectomy site is unavailable 12 (see Figure S2 and Table S1 ). Kern Decompressive hemicraniectomy for stroke in older adults: a review Outcomes of decompressive craniectomy in patients after traumatic brain injury Role of transcranial doppler in neurocritical care Bedside detection of acute epidural hematoma by transcranial sonography in a head-injured patient Intracranial epidural hematoma follow-up using bidimensional ultrasound. Rev Bras Ter Inten-siva Rapid detection of recurrent intraventricular hemorrhage by ultrasound in a multiple trauma patient who had undergone craniectomy Usefulness of transcranial echography in patients with decompressive craniectomy: a comparison with computed tomography scan Transcranial color-coded duplex sonography of intracerebral hematomas in adults Differentiation between ischemic and hemorrhagic stroke by transcranial color coded real-time sonography Neonatal and Infant Brain Imaging Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries Echography in brain imaging in intensive care unit: state of the art Multiplanar transcranial ultrasound imaging: standards, landmarks and correlation with magnetic resonance imaging Transcranial grey-scale sonography of subdural haematoma in adults Evaluation of the ventricular system in adults by transcranial duplex sonography Authors have no conflicts of interest to disclose. Additional supporting information may be found online in the Supporting Information section at the end of the article.