Objective: To identify factors associated with treatment modality selection in acoustic neuromas. Study Design: Prospective observational study. Setting: Tertiary care neurotology clinic. Patients: Data were prospectively collected from patients initially presenting to a tertiary care neurotology clinic between 2013 and 2016. Patients who did not have magnetic resonance imaging (MRI), demographic, psychometric, or audiometric data were excluded from analysis. Intervention: Demographic information, clinical symptoms, tumor characteristics, and psychometric data were collected to determine factors associated with undergoing acoustic neuroma surgical resection using univariate and multiple logistic regression analysis. Main Outcome Measure: The decision to pursue acoustic neuroma surgical resection versus active surveillance. Results: A total of 216 patients with acoustic neuroma (mean age 55 years, 58% women) were included. Ninety eight patients (45.4%) pursued surgical resection, 118 patients (54.6%) pursued active surveillance. Surgical treatment was significantly associated with patient age less than 65, higher grade tumors, growing tumors, larger volume tumors, lower word discrimination scores, Class D hearing, headache, and vertigo as presenting symptoms, higher number of total symptoms, and higher headache severity scores (p<0.05). There was no significant association between surgical intervention and preoperative quality of life, depression, and self-esteem scores. On multiple logistic regression analysis, the likelihood of undergoing surgical resection significantly decreased for patients older than age 65 (odds ratio [OR] 0.19; 0.05-0.69) and increased in patients with medium (OR 4.34; 1.36-13.81), moderately large (OR 33.47; 5.72-195.83), large grade tumors (OR 56.63; 4.02518.93), tumor growth present (OR 4.51; 1.66-12.28), Class D hearing (OR 3.96; 1.29-12.16), and higher headache severity scores (OR 1.03; 95% confidence interval [CI] 1.011.05). The likelihood of undergoing surgical resection was completely predictive for giant grade tumors and not significant for small grade tumors and Class B or C hearing. Conclusions: Non-elderly acoustic neuroma patients with larger tumors, growing tumors, significant hearing loss, and worse headaches are more likely to pursue surgical resection rather than active surveillance. Psychological factors such as quality of life, depression, and self-esteem do not seem to influence decision-making in this patient population.