For patients who suffer from hydrocephalus that is difficult to treat because of impaired intracranial compliance, a programmable shunt system may be a helpful alternative. However, especially during the first weeks after implantation, many radiological follow-up studies are necessary to achieve the optimum pressure level. The authors present the case of a 7-year-old boy who suffered from posthemorrhagic hydrocephalus and did not respond to conventional shunt valve systems. After implantation of a programmable shunt system, achieving the optimum craniospinal fluid (CSF) pressure level was difficult because the symptoms of over-and underdrainage were similar. Using transcranial real-time ultrasonography for evaluation of the diameter of the intracranial CSF spaces, we were able to adjust the correct pressure level without long-term intracranial pressure monitoring or daily computed tomography, which otherwise would have been necessary because of the ambiguous symptomatology. Transcranial real-time ultrasonography (TCUS) displays an image of the intracranial parenchyma and CSF spaces through the intact temporal bone and is a valuable, serially applicable bedside monitoring technique for patients requiring close imaging follow-up.