Minimal access awake craniotomy for drainage of cerebral abscess in a patient with severe complex cardiac defects in resource-limited country: A case report

INTRODUCTION AND IMPORTANCE: Brain abscess is an uncommon but potentially fatal infection of the brain parenchyma that can affect 5 % to 18.7 % of people with uncorrected complex congenital heart defects. In management of patients with complex cardiac defects, the main concern is that they are prone to develop perioperative complications. Hence such cases are a real challenge for surgeons and anesthesiologists. In this study we have reported a well-managed awake craniotomy (Awake-Asleep-Awake) for drainage of cerebral abscess in a patient with complex cardiac defect. CASE PRESENTATION: We present a case of a 13-year-old male patient with untreated cyanotic CHD-TOF with complete AV canal defect, who complained of right-side paralysis since 2 weeks; and has been suffering from headache, fever and vomiting for 25 days. Brain CT scan showed a large abscess in the left fronto-temporal lobes. Minimal access awake craniotomy with regional scalp nerve block and sedation was done and about 100-120 cc thick pus was drained. The patient's paralysis improved significantly and neurological deficit ceased on 3rd postoperative day. CLINICAL DISCUSSION: Pediatric population itself is a challenge for anesthesiologists and this manifolds when associated with complex cardiac defects and neurosurgery cases. CONCLUSION: Brain abscess is expected to be more common in patients following uncorrected complex congenital heart disease in developing countries. Physicians must hold a high index of suspicion for early diagnosis and well-management of these patients with multidisciplinary approach. Minimal access awake craniotomy with or without sedation for patients with large brain abscess is a safe surgical approach.