Neuroanesthetic management of cerebral abscess in Tetralogy of Fallot: balancing intracranial and cardiac risks

Abstract

Cerebral abscess is a rare but serious intracranial infection, particularly in paediatric patients with cyanotic congenital heart disease (CCHD) such as Tetralogy of Fallot (TOF). In TOF, the presence of a right-to-left shunt facilitates haematogenous spread of bacteria to the brain. Chronic hypoxaemia leads to polycythaemia and increased blood viscosity, contributing to cerebral abscess formation.
A four-year-old boy presented with a right temporoparietal cerebral abscess in the context of uncorrected TOF. He complained of recurrent vomiting, fever, headache, and cyanosis, with oxygen saturation as low as 86%. CT scan revealed a 4.4×3.6×4.0 cm abscess with significant perilesional oedema. The patient underwent craniotomy and abscess drainage under general anesthesia. Induction was performed using a ketamine-propofol combination, while maintenance was achieved with 1% sevoflurane. The surgery proceeded uneventfully with successful drainage of 30mL of purulent material.
The anesthetic strategy prioritised hemodynamic stability and adequate cerebral perfusion. The ketamine-propofol combination was selected for its ability to preserve systemic vascular resistance while avoiding a rise in ICP. Steroids were deliberately omitted in line with recent evidence suggesting increased risk of infectious complications. Postoperative analgesia was managed with a multimodal opioid-sparing regimen to allow prompt and reliable neurological assessment, which proved effective.

Conclusion: Careful anesthetic management using ketamine-propofol induction, controlled ventilation, and
appropriate hydration proved successful in managing this complex case of cerebral abscess in TOF. Multidisciplinary coordination was pivotal, particularly in a resource-limited healthcare setting.

Keywords: Cerebral abscess; Neuroanesthesia; Tetralogy of Fallot.

Citation: Cobis AY, Bisri DY, Rachman IA.Neuroanesthetic management of cerebral abscess in Tetralogy of Fallot:
balancing intracranial and cardiac risks. Anaesth. pain intensive care 2025;29(9):1321-26. DOI:
10.35975/apic.v29i9.3074

Received: August 23, 2025; Revised: October 10, 2025; Accepted: October 27, 2025