Anaesthesia for the posterior fossa provides a unique challenge for anaesthetists and neurosurgeons. Optimal patient positioning should facilitate surgical access without compromising patient safety. The important considerations are surgical access, securing and maintaining the airway, maintenance of adequate anaesthetic depth, haemodynamic stability and oxygenation. Care should be taken to limit the 'blackout state' during which the patient is not monitored or connected to the breathing circuits during patient transfer or positioning on the operating table. The hazards during positioning can be reduced by meticulous planning, careful positioning and vigilance to facilitate early detection of complications. The aim of maintenance of anaesthesia is to reduce the intracranial pressure (ICP) and to maintain haemodynamic stability. Anaesthesia can be maintained with either volatile agents or intravenous agents such as propofol. The choice of the anaesthetic agent is at the discretion of the individual anaesthetist.