Serial Transcranial Doppler Monitoring in a Patient with Acyanotic Congenital Heart Disease Undergoing Endoscopic Third Ventriculostomy: An Anesthetic Perspective

Endoscopic third ventriculostomy (ETV) is associated with abrupt intracranial pressure fluctuations and risk of venous air embolism. In patients with acyanotic congenital heart disease (ACHD) and residual intracardiac shunts, perioperative physiological alterations may result in transient shunt reversal, increasing the risk of paradoxical cerebral embolism. We report the anesthetic management of a pediatric patient with ACHD, a persistent atrial septal defect, and a patent ductus arteriosus device in situ undergoing ETV, in whom serial intraoperative transcranial Doppler (TCD) monitoring was employed as a neurocentric safety adjunct. Middle cerebral artery flow velocities were assessed at predefined perioperative milestones, including induction, ventricular access and irrigation, and emergence. TCD demonstrated stable cerebral blood flow velocities without microembolic signals or downstream Doppler evidence suggestive of major cerebral hemodynamic disturbance during the monitored perioperative stages. The intraoperative and postoperative courses were uneventful, with no new neurological deficits. This case highlights the feasibility of serial, milestone-based TCD monitoring as an adjunct to anesthetic vigilance by providing surrogate information on cerebral hemodynamic stability during neuroendoscopic surgery in a pediatric patient with an intracardiac shunt.