The purpose of our study was to investigate the pattern of recurrence and the prognostic factors for recurrence of pediatric craniopharyngiomas after radical excision. A series of 36 patients with craniopharyngiomas (21 boys and 15 girls; age range 1-15 years; mean 7.3 years) were reviewed. All patients had undergone radical excision without radiotherapy. The mean follow-up period was 52 months (range 1-149 months). Tumors recurred in 14 patients within 83 months (mean 31.4 months). The overall 5-year recurrence-free survival rate was 55%. Regular neuroimaging follow-up detected tumor recurrence while the lesions were still small before symptoms developed (P<0.05). At the first surgical procedure, the optic nerve/chiasm (n=23) was the most common adhesion site. The most frequent sites of recurrence were the optic nerve/chiasm (n=6) and the pituitary fossa (n=6). Tumor location was the single significant clinical predictor of recurrence. The 5-year recurrence-free survival rate was 39% for those who had an intrasellar tumor component and 81% for those who did not (P<0.05). The Ki-67 labeling indices (LIs) of primary tumors did not have prognostic value for recurrence. Recurrent tumors tended to have higher Ki-67 LIs than their primary counterparts. On the basis of this study, we concluded that craniopharyngiomas with intrasellar components should be followed cautiously and the necessity for regular follow-up should be emphasized, even when the tumor is "totally" resected.