Pilocytic astrocytoma (PA) is a low-grade tumor. It has an excellent prognosis after total resection. Leptomeningeal dissemination and hemorrhage are very rare to be associated with PA and lead to unfavorable prognosis. A 35-year-old man was diagnosed with a hemorrhagic suprasellar PA in 2006. Subsequent examination in 2007 revealed another large subdural hemorrhagic lesion in the sacral region, which proved to be PA by histopathologic assessment. Other leptomeningeal foci were discovered mainly at the craniocervical junction. The patient underwent subtotal resection and received chemotherapy with disease control for 7 years. Progression of the disseminated disease has recently occurred; however, the patient is still alive with stable disease after radiotherapy. The radiological features, management, and relevant literature are also presented. Our report heightens the awareness of PA in the adult population and the importance of close surveillance for the leptomeningeal spread, especially for sellar region tumors.