Contrast-Enhanced NeuroPOCUS in Neurocritical Care: Overcoming Technical Barriers to Bedside Transcranial Ultrasound.

Neuro-point-of-care ultrasound (NeuroPOCUS) is an emerging bedside modality that extends the neurological examination through real-time assessment of cerebral structure and hemodynamics in neurocritical care. Despite increasing integration into clinical pathways and endorsement of transcranial ultrasound-based neuromonitoring by international guidelines, implementation is often hampered by inadequate acoustic windows and poor image and Doppler signal quality, frequently leading to nondiagnostic examinations. Ultrasound contrast agents (UCAs), traditionally used in specialist neurosonology, may overcome these barriers and recover diagnostic information in patients with limited acoustic windows. This clinically oriented narrative review synthesizes the available evidence on contrast-enhanced transcranial ultrasound and examines its potential translation into NeuroPOCUS as a bedside tool for frontline clinicians across vasospasm monitoring, intracranial pressure assessment, evaluation of steno-occlusive cerebrovascular disease, assessment of cerebral circulatory arrest, and other neurocritical care applications. A literature search of PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Scopus was conducted through June 2026, and relevant studies, reviews, and guideline documents were descriptively synthesized according to clinical application. Available evidence indicates that UCAs improve Doppler signal quality, enhance visualization of intracranial vessels, and increase the proportion of diagnostic examinations in patients with limited acoustic windows, thereby improving the interpretability of bedside hemodynamic assessments. However, implementation remains constrained by operator dependence, heterogeneous acquisition and interpretation protocols, limited standardization, and the need for structured training and validated, application-specific velocity cutoffs. Looking ahead, contrast enhancement may expand the scope of bedside neurovascular assessment, including in emergency and acute-care settings where dedicated probes and presets are not readily available. Its favorable safety profile and enhanced bedside feasibility may help bridge the gap between guideline recommendations and clinical practice, although further technical and clinical validation is needed to define its role in frontline NeuroPOCUS.