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To assess the agreement between computed tomography and transcranial sonography in patients after decompressive craniectomy.Prospective study.The medical intensive care unit of a university-affiliated teaching hospital.Thirty head-injured patients consecutively admitted to the intensive care unit of “A. Gemelli” Hospital who underwent decompressive craniectomy were studied. Immediately before brain cranial tomography, transcranial ultrasonography was performed.The mean difference between computed tomography and echography in measuring the dislocation of midline structures was 0.3 ± 1.6 mm (95% confidence interval 0.2–0.9 mm; intraclass correlation coefficient, 0.979; p< .01). An excellent correlation was found between computed tomography and transcranial sonography in assessing volumes of hyperdense lesions (intraclass correlation coefficient, 0.993; p< .01). Lesions that appear hypodense on computed tomography scan were divided in ischemic and late hemorrhagic. No ischemic lesion was localized on echography; a poor correlation was found between computed tomography and echography in assessing the volume of late hemorrhagic lesions (intraclass correlation coefficient, 0.151; p= .53). A quite good correlation between transcranial ultrasonography and computed tomography was found in measuring lateral ventricles width (intraclass correlation coefficient, 0.967; p< .01). Sensitivity and specificity of transcranial ultrasonography in comparison with computed tomography to detect the position of intracranial pressure catheter was 100% and 78%.Echography may be a valid option to computed tomography in patients with decompressive craniectomy to assess the size of acute hemorrhagic lesions, to measure midline structures and the width of lateral ventricles, and to visualize the tip of the ventricular catheter.