Brain Abscess Drainage in a Case of Tetralogy of Fallot with Pulmonary Atresia with Major Aortopulmonary Collateral Arteries Under Scalp Block

Abstract

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. There are a few reports of uncorrected TOF patients surviving into adulthood requiring noncardiac surgery. They are commonly susceptible to developing brain abscesses due to paradoxical embolism and lack of pulmonary phagocytic clearance. A 32-year-old man, a known patient of TOF with pulmonary atresia and major aortopulmonary collateral arteries, presented with left side weakness and seizures. He was drowsy with a Glasgow Coma Scale (GCS) of 13/15, heart rate of 72/min, oxygen saturation of 78% with 6 L/min oxygen via face mask, and blood pressure of 90/60 mm Hg with noradrenaline at 0.5 mcg/kg/min. He had central cyanosis, clubbing, and icterus. The left upper and lower limb power was 2/5, whereas it was 5/5 for the right. Cardiovascular examination revealed a grade 3/6 continuous murmur at the base of the heart. No pulmonary abnormality was noted on auscultation. Echocardiography showed large subaortic ventricular septal defect (VSD) with overriding of the aorta, pulmonary atresia, right-sided aortic arch, and ejection fraction of 62%. Magnetic resonance imaging (MRI) of the brain revealed features suggestive of brain abscess. Brain abscess drainage was performed under scalp block with sedation to avoid major hemodynamic fluctuations. The procedure was uneventful, and the patient's power on the left side improved postprocedure. Scalp block with sedation is a suitable alternative to general anesthesia for drainage of brain abscess in TOF patients.

Keywords

• brain abscess
• congenital heart disease
• pulmonary atresia
• scalp block
• tetralogy of Fallot