Purpose <p>In Neurosurgery, stereotactic biopsy represents the main minimally invasive surgical technique to target deep and hard-to-reach brain sites that are not accessible by traditional surgical methods. The best trajectory for biopsy needle insertion is planned on the basis of CT or MRI studies. According to the relevant literature, although biopsy of the posterior cranial fossa with Leksell® Vantage™ Head Frame is possible, it involves several technical and clinical challenges. We describe an alternative configuration of the Leksell® Vantage™ system that addresses these limitations in the management of posterior cranial fossa lesions.</p> Methods <p>At our Department (IRCCS Ospedale Policlinico San Martino in Genoa) we have used Leksell® Vantage™ stereotactic system together with Medtronic StealthStation™ S8 planning software to perform a series of seven stereotactic biopsies in the occipital or cerebellar region by rotating the stereotactic helmet 180° on the axial plane, resulting in an inversion of both the anteroposterior and lateral–lateral axes.</p> Results <p>We demonstrate that stereotactic posterior fossa biopsies can be performed with helmet rotation, without additional procedural complications. No similar approach has previously been described in the literature.</p> Conclusion <p>This approach significantly enhances access to the posterior cranial fossa and occipital lesions. This optimisation improves manoeuvrability, provides a more advantageous viewing angle for the needle-biopsy trajectory and allows for a less complex preoperative planning. The approach remains minimally invasive and is generally compatible with execution under conscious sedation.</p>