Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 06 22 1574 1574 Muhammad Aditya Departement of Anesthesiology and Intensive Care, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia. & Department of Anesthesiology and Intensive Care, Dr. Moewardi General Hospital, Faculty of Medicine, Universitas Sebelas Maret, Central Java, Indonesia. Christopher Kapuangan Departement of Anesthesiology and Intensive Care, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia. Setia Mustajabah Department of Anesthesiology and Intensive Care, Dr. Moewardi General Hospital, Faculty of Medicine, Universitas Sebelas Maret, Central Java, Indonesia. 2026 02 15 2026 02 23 Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease and poses significant anesthetic challenges, especially during neurosurgical procedures. Patients require maintenance of systemic vascular resistance (SVR) to prevent worsening right-to-left shunting, while neurosurgery necessitates strict control of intracranial pressure (ICP) and cerebral perfusion. Balancing these conflicting priorities demands an individualized, multidisciplinary approach. We report a 7-year-old girl (15 kg) with uncorrected TOF and a cerebral abscess requiring emergency craniotomy. Preoperative evaluation revealed central cyanosis, right-sided hemiparesis, and oxygen saturation of 50%. Cranial CT showed a left parietal abscess with subfalcine herniation. Anesthetic induction used fentanyl, midazolam, low-dose ketamine, and rocuronium, with sevoflurane for maintenance. Ketamine was selected to preserve SVR and prevent hypercyanotic spells, despite concerns of increased ICP. Intraoperative hemodynamics remained stable, and postoperative recovery was uneventful. At the six-month follow-up, the patient showed complete neurological recovery without additional complications. The anesthetic management of uncorrected TOF with concurrent neurosurgical pathology demands physiology-driven drug selection, vigilant monitoring, and team coordination. This case highlights the importance of balancing SVR, PVR, and ICP, demonstrating that carefully titrated ketamine remains a safe and effective option in complex TOF neurosurgical scenarios. https://aacc.tums.ac.ir/index.php/aacc/article/view/1574