• Shuntaro Togashi, Jun Maruya, Hideaki Abe, Keiichi Nishimaki, Haruka Ouchi, Kenju Hara, Takuo Tokairin, Kenichi Nishiyama, and Hiroaki Shimizu.
• Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan; Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan. Electronic address: togashi@med.akita-u.ac.jp.
• World Neurosurg. 2020 Dec 1; 144: 121-124.

BackgroundRecurrent hydrocephalus may occur as a complication of neurosarcoidosis with chronic inflammation. We present a case that required a combination of multistage endoscopic diversion of the cerebrospinal fluid pathway and shunt surgery.Case DescriptionA 34-year-old man presented with progressive nausea and vomiting. Magnetic resonance imaging revealed hydrocephalus with leptomeningeal enhancement along the base of the fourth ventricle and the bilateral foramina of Luschka. Concurrent endoscopic third ventriculostomy and biopsy were performed. The diagnosis was neurosarcoidosis. Immediately after the procedure, the endoscopic third ventriculostomy stoma was occluded, and a right ventriculoperitoneal shunt was urgently performed. However, left unilateral hydrocephalus developed during the late phase of immunosuppressive therapy for neurosarcoidosis. Endoscopic septostomy with repositioning of the ventricular catheter was indicated. Intraoperative findings included a white pasty tissue with nodules that covered the ventricular wall close to the foramen of Monro and sealed the side holes of the catheter. Chemotherapy with a tumor necrosis factor-α inhibitor was initiated after the surgical procedure. The patient had an uneventful course without recurrence of hydrocephalus for >6 months.ConclusionsEndoscopic diversion of the cerebrospinal fluid pathway should be actively considered for treating hydrocephalus without a shunt and performing biopsy simultaneously. Even if a subsequent shunt is needed, complex hydrocephalus can be avoided with a combination of endoscopic techniques.Copyright © 2020 Elsevier Inc. All rights reserved.

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