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Tetratology of Fallot (TOF) is a rare congenital heart defect with Ventricular septal defect (VSD) as one of its four components. VSD predisposes this set of patients to developing complications of which brain abscess is one, due to shunting of blood from the right to left ventricle and concomitant loss of innate immunity of pulmonary filtering and removal of bacteria, clot and other organisms in blood from the right heart. Surgical evacuation of brain abscess in patients with background TOF could be challenging as administering anaesthesia could increase morbidity, mortality and pose great risk to this set of patients. We report a case of a six-year-old male child with an uncorrected TOF who developed multiple brain abscess and had surgical intervention (burr-hole and evacuation of abscesses) under general anaesthesia, and our challenges in a resource-limited hospital setting. A good anaesthetic plan, selection of appropriate anaesthetic medications to prevent right to left shunting of blood in the heart, using a pure alpha-receptor agonist; Phenylephrine, and excellent surgical intervention were major determinant of this patient survival without apparent neurological sequelae.