Cerebral Parenchymal Probe Placement with Extreme Limitation of Cranial Bone

right-handed patient presented to an outside hospital with wakeup stroke. His deficit was complete right-sided weakness and marked aphasia. He was out of recombinant tissue plasminogen activator (rTPA) window and his CT scan showed early left middle cerebral artery (LMCA) stroke (Fig. 1A). There was a dense clot present in the first segment of LMCA. He was sent to comprehensive stroke center for an embolectomy attempt. On arrival a perfusion magnetic resonance imaging (MRI) brain was done which confirmed no viable penumbra and major LMCA area stroke. He was intubated prior to this MRI due to decline in neurological status. He was admitted to neurocritical care unit for close neuro checks. His repeat CT scan in 12 hours showed worsen cerebral edema and shift from left to right. At that stage an emergent left side decompressive hemicraniectomy was performed. Follow-up CT brain in 6 hours showed progressive cerebral edema. His postoperative CT skull showed extremely limited bone over left frontal area (Fig. 1B). A decision was made to place PPP. Raumedic ® bolt was selected. Left limited forehead area was evaluated for the access site. Sagittal images showed minimal area behind the resection and cephalad to frontal sinus (Fig. 1C). The bolt was placed with an opening pressure of 26 mm Hg. His repeat CT scan showed appropriate placement of the probe without any complications. to this article: Janjua T, Souslian Meyer SA, et al. Cerebral Parenchymal Probe Placement with Extreme Limitation of Cranial Bone. Panam J Trauma Crit Emerg 2021;10(3):147–149. Neurocritical care monitoring is prudent for the close neurological evaluation and adjustment of the treatment. Neuromonitoring allows the identification and evaluation of various physiological variables that can be modified after the primary injury. In severe TBI management, the use of intracranial probe is part of the advanced management of the neurocritical patient. Decompressive craniectomy, focal brain surgery, fracture skull, and previous prothesis makes it extremely tricky to achieve cerebral parenchymal probe placement (PPP).