Postoperative transient sympathetic storm after endoscopic third ventriculostomy with choroid plexus cauterization in pediatric hydrocephalus.

Background: In recent years, the use of endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV + CPC) for the treatment of pediatric hydrocephalus has gained increasing attention, particularly in North America and Africa. It has shown potential to enhance the efficacy of ETV alone and reduce the need for ventriculoperitoneal shunt placement. However, research on the potential side effects of CPC, particularly concerning postoperative sympathetic nervous system responses, remains limited. In our clinical practice, we observed that ETV + CPC may induce transient sympathetic storms, a phenomenon not yet reported in the literature, posing new challenges for postoperative anesthetic management and monitoring. Objective: This study aims to report the phenomenon of transient sympathetic storm following ETV + CPC, analyze its potential mechanisms, and raise awareness among anesthesiologists and neurosurgeons to enhance recognition and management of this condition. Methods: A retrospective analysis was performed on three pediatric patients with communicating hydrocephalus who underwent ETV + CPC at our hospital between January 2016 and December 2016 and subsequently developed transient sympathetic storm. The clinical features, intraoperative and postoperative conditions, and patient outcomes were analyzed to explore the relationship between the extent of CPC and the severity of sympathetic hyperactivity. Results: All three patients developed varying degrees of sympathetic hyperactivity after surgery, including tachycardia, rapid breathing, increased muscle tone, tension, and limb tremors. The first case (6-month-old boy) underwent right-sided CPC and had the mildest response. The second case (6-month-old girl) underwent right-sided and partial left-sided CPC, exhibiting moderate response. The third case (21-month-old girl) underwent extensive bilateral CPC and had the most severe response with the longest duration. Sympathetic hyperactivity was positively correlated with the extent and intensity of CPC. Conclusion: Transient sympathetic storm may occur after ETV + CPC, presenting challenges for postoperative anesthetic and neurosurgical care. The severity of sympathetic hyperactivity appears to correlate with the extent and intensity of CPC. Its mechanism is hypothesized to involve thermal injury to the bilateral thalamus and associated vasculature. Further research is required to better understand the side effects and complications of CPC. This study also supports the hypothesis that bilateral thalamic injury may trigger sympathetic hyperactivity, providing new evidence and insights into the mechanisms underlying paroxysmal sympathetic hyperactivity.