(1) Background: Superior cerebellar peduncle (SCP) lesions are sparsely reported in the literature. The surgical approaches to the cerebello-mesencephalic region remain challenging. In this article, we present the extreme lateral supracerebellar infratentorial (ELSI) approach to treat a large hemorrhagic pilocytic astrocytoma of the SCP. (2) Methods: An 11-year-old boy, known for neurofibromatosis Type I, presented to the emergency department of our institution with symptoms and signs of intracranial hypertension. The cerebral magnetic resonance imaging (MRI) revealed a large hemorrhagic lesion centered on the SCP provoking obstructive hydrocephalus. Following an emergency endoscopic third ventriculocisternostomy (ETV), he underwent a tumor resection via an endoscope-assisted ELSI approach. (3) Results: ELSI approach allows for a wide exposure with direct access to lesions of the SCP. The post-operative course was uneventful, and the patient was discharged home on post-operative day 5. Post-operative MRI revealed a near total resection with a small residual tumor within the mesencephalon. (4) Conclusion: ELSI approach offers an excellent exposure with the surgical angles necessary for median and paramedian lesions. The park-bench position with appropriate head flexion and rotation offers a gravity-assisted relaxation of the tentorial and petrosal cerebellar surfaces. The endoscope can be an adjunct to illuminate the blind areas of the surgical corridor for an improved tumor resection without significant cerebellar retraction.