Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10–20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.

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A 48 year old man presented with a four day history of lethargy, dizziness, and an unsteady gait with recurrent falls, on a background of chronic alcohol misuse. The patient was taking desmopressin for nocturnal enuresis and bendroflumethiazide for hypertension, which were both stopped on admission.On physical examination he appeared clinically euvolaemic and he had no focal neurological deficit. Vital signs were within normal limits. Serum biochemistry showed sodium of 110 mmol/L (normal range 137-145; 1 mmol/L=1mEq/L) and potassium of 2.6 mmol/L (normal range 3.5-5.5 mmol/L). A computed tomogram of the brain that was performed to rule out traumatic brain injury was unremarkable.Fluids were subsequently restricted and he was started on parenteral thiamine, oral chlordiazepoxide, and intravenous 0.9% sodium chloride with potassium supplementation. Twenty four hours later, serum sodium was 119 mmol/L and serum potassium was 3.3 mmol/L. Serum sodium eventually reached 130 mmol/L on day 4. Seven days after admission he developed delirium and on examination had bilateral pyramidal weakness, more pronounced on the right. Reflexes were generally brisk, with bilateral extensor plantar responses. He also developed mild dysarthria but there was no dysphagia.

Gas under the diaphragm can be due to like perforation in stomach, duodenum due to peptic ulcer disease, in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum. We present a rare cause of pneumoperitoneum following abdominal hysterectomy.