Immediate emergence after neurosurgery is desirable to facilitate neurologic examination and early identification of complications. Awakening is determined by many factors including preoperative status, type of surgery, and intraoperative events. This chapter presents a case study of a 58-year-old female with a body mass index of 32 who complained about gradual hearing loss, increasing frequency of headaches and vertigo and subsequently was diagnosed with an acoustic neuroma. In order to facilitate early detection of neurologic complications, anesthesiologists usually aim for an early emergence following intracranial surgery. The most common causes of delayed postoperative emergence include residual drug effects, respiratory failure, metabolic derangements, and neurologic complications. Cerebral swelling can occur intraoperatively or preexist. In the context of posterior fossa surgery this is of particular concern. Multiple factors contribute to a delayed emergence from anesthesia and a systematic approach to rule out all possible causes is necessary.