BACKGROUND Neurocysticercosis is a parasitic infection of the central nervous system caused by the helminth Taenia solium . Racemose neurocysticercosis is a rare form of the disease that specifically involves cerebrospinal fluid–filled spaces in the brain and carries a high rate of complications and mortality. OBSERVATIONS This report describes the case of a 37-year-old man who developed headaches and nausea, which were found to be secondary to racemose neurocysticercosis. He ultimately required an endoscopic third ventriculostomy, which provided transient symptom relief. In the weeks following the procedure, his symptoms returned, at which point a recommendation to proceed with a ventriculoperitoneal shunt was made. LESSONS The presentation of racemose neurocysticercosis is wide-ranging and often nonspecific. Patients who respond well to initial surgical management with endoscopic third ventriculostomy can still require more durable measures, such as a ventriculoperitoneal shunt, in the following months. https://thejns.org/doi/10.3171/CASE24489