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OBJECTIVE: Pilocytic astrocytomas are extremely rare in octagenarians especially those occurring in the third ventricle. They are similar histopathologically to pilomyxoid astrocytomas but the latter are more aggressive. We report the case of an 86-year old patient presenting with confusion and lethargy secondary to a third ventricular lesion causing obstructive hydrocephalus. The lesion was approached endoscopically and sub-totally resected. Histologically the lesion was classified as a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery and did not require a shunt. MATERIALS AND METHODS: Case report with pictures and video of the operative approach as well as discussion of the imaging sequences and histology, and review of the literature. RESULTS: Sub-total resection of the tumour was achieved using a monoportal image-guided endoscopic approach. Normal cerebrospinal fluid circulation was restored and a shunt was not required. Histologically, the mass was confirmed to be a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery with resolution of her symptoms. No such case has been reported in the literature to date. CONCLUSION: This is the first report of a third-ventricular pilocytic astrocytomas with pilomyxoid features in an octogenarian. The endoscopic approach in the case at hand, allowed safe direct visualisation and sub-total resection of the lesion, providing histological diagnosis to guide management and obviating the need for a shunt. The minimally invasive nature of the approach translated into full recovery, despite the age of the patient.