Mitral valve disease in patients undergoing posterior fossa surgery enhances the inherent risk of the procedure and can complicate the anesthetic management. A great challenge for the anesthesiologist is to choose the most appropriate perioperative technique that balances the specific anesthetic considerations of both the cardiac and the neurologic diseases. The authors describe the anesthetic management of a patient with a meningioma in the posterior fossa requiring craniectomy and tumor decompression. She was also diagnosed with severe mitral regurgitation and moderate mitral stenosis.