Management options for patients with vestibular schwannomas (acoustic neuromas) include observation, resection, stereotactic radiosurgery, or fractionated radiotherapy. In this report, we review our experience with radiosurgery over a 20-year interval, and discuss indications and expectations with the different approaches. There has been an evolution in available technologies, and an evolution in both patient and physician approaches to the management of this tumor. Patient decisions must be based on quality information from the peer-reviewed literature. Future concepts for radiosurgery are discussed.