Comparison of midline shift and ventricular size measured by transcranial ultrasound and non-contrast computed tomography in patients with acute subdural hemorrhage undergoing decompressive craniectomy: A prospective observational study

Background: Managing traumatic brain injury (TBI) involves complex monitoring, especially of elevated intracranial pressure. Transcranial ultrasound (TCUS) is emerging as a useful bedside tool for assessing optic nerve sheath diameter, cerebral blood flow velocities, midline shift, ventricle size, and complications. This study compares midline shift and ventricle size measurements obtained using TCUS and non-contrast computed tomography (NCCT) in patients with acute subdural hematoma (SDH) who underwent emergency decompressive craniectomy (DC). Methods: Sixty consecutive patients who underwent DC for acute SDH were enrolled. TCUS was performed before NCCT, which was done 12–24 h post-surgery. Midline shift and ventricular size (lateral and third ventricles) were assessed on both imaging modalities. Secondary parameters, including hematoma, contusion, parenchymal changes, and basal cistern patency, were also evaluated. Results: TCUS demonstrated a strong correlation with NCCT for midline shift (r = 0.984, P < 0.001). Ventricular measurements showed good correlation – lateral ventricle (r = 0.667) and third ventricle (r = 0.914, P < 0.001). Bland-Altman analysis confirmed strong agreement. Hematoma (kappa = 1) and contusion (kappa = 0.8) showed a strong correlation. Moderate agreement was noted for parenchymal changes and basal cistern patency. TCUS was comparable to NCCT in detecting hemorrhage and parenchymal abnormalities, but less sensitive for contusion and cistern evaluation. Conclusion: TCUS shows excellent correlation with NCCT in evaluating midline shift and good correlation for ventricular size post-DC. It is a reliable, non-invasive bedside modality for postoperative monitoring in TBI patients.