A 60-year-old woman had an incidental diagnosis of right clinoid meningioma. The lesion was about 2 cm diameter with moderate PTBE [Figure 3a]. She underwent upfront GKR in five fractions (PTV 6.263 cm3, 25 Gy isodose 50%) at another Institution. In this patient, the procedure was performed with Gamma Knife Icon, 5 Gy per fraction. Eight months later, she started to complain of headache, dizziness, and asthenia. A brain MRI showed a significant increase in PTBE with compression of the frontal horn of the right lateral ventricle and a millimetric shift of the midline. At that time, surgical treatment was excluded due to possible risks of swelling related to extensive PTBE. Therefore, long lasting high-dose corticosteroid therapy was instituted without benefit, while iatrogenic Cushing disease and psychiatric disorders appeared. She presented at our institution after 12 months and, in light of our previous experience, we proposed radical surgical removal of the lesion. The brain did not appear swollen, allowing the removal of the tumor without the use of retractors. Histopathological examination confirmed a meningothelial meningioma (Grade I WHO) [Figure 3b]. Steroids were immediately reduced and a rapid improvement in symptoms was observed in a few weeks. A brain MRI performed 2 months after surgery showed near complete resolution of the pre-existing PTBE [Figure 3c and d]. At 2 year follow-up, the patient is well and brain MRI does not show tumor recurrence.