OBJECTIVES: Surgical resection is a primary indication for intracranial meningioma. Radiosurgery is also an excellent treatment modality for postoperative residual tumors, or tumors in high-risk locations, such as the skull base. Despite multimodality treatments, there are some cases in which radiosurgery fails and surgical resection or re-radiosurgery is required. However, there has not been a comprehensive study focusing on the causes of secondary treatment for local recurrence or a new mass that develops outside the target area after radiosurgery. Hence, we analyzed the causes of radiosurgical failure in patients with meningioma. METHODS: From 2000 to 2015, we retrospectively reviewed 1086 patients who underwent gamma knife radiosurgery (GKRS) for intracranial meningioma at the Asan Medical Center. Multiple meningiomas or tumors with a volume greater than 7000mm were excluded. All patients had a minimum follow-up of 12 months. Finally, 771 patients were enrolled in this study. Clinical symptoms and brain MRI findings were assessed by neurosurgeons. When the tumor size increased and was accompanied by newly developed neurological symptoms, further management was considered (e.g. microsurgical resection and stereotactic radiosurgery). Histological analyses of the resected tumors were performed by neuropathologists. RESULTS: Among the 771 patients, tumor growth was observed in 60 patients (7.78%). Seven patients showed transient tumor growth after GKRS. These patients have been under close observation without any further treatment. Thirty patients (3.89%) underwent re-radiosurgery for tumor control. Another 23 patients underwent procedures other than re-radiosurgery; 8 underwent microsurgical resection, 3 underwent cyber knife radiosurgery (CKRS), 1 underwent radiation therapy, and 8 were closely followed-up. Three patients visited other clinics or were lost to follow-up. Of the remaining 30 patients, 22 (group 1) underwent microsurgical resection prior to their initial course of GKRS and the other 8 (group 2) were treated only with re-radiosurgery. In group 1, recurrence rates after radiosurgery were 2.47% (n=19) and 0.39% (n=3) for local and distant recurrence, respectively. In group 2, recurrence rates after radiosurgery were 0.52% (n=4) and 0.52% (n=4) for local and distant recurrence, respectively. An analysis was performed to determine the factors that may result in differences between the two groups. Of the many variables, local recurrence (p=0.0331, Fisher's exact test) was the only significant factor. CONCLUSION: We analyzed the causes of radiosurgical failure in meningioma patients and observed that microsurgery before radiosurgery was significantly associated with a high local recurrence rate compared with primary radiosurgery. Furthermore, the percentage of local recurrence cases that required secondary radiosurgery was as low as 2.98%. This result is comparable with that of microsurgical resection, which is the mainstay of treatment for meningioma.