Juvenile nasopharyngeal angiofibroma involving the cavernous sinus: Does surgery have a role?

Axial T1W post-contrast MRI scan shows an intensely enhancing mass centred on the left sphenopalatine foramen which is expanded (white arrows) and extending into the posterior nasal cavity, pterygopalatine fossa and infratemporal fossa. There are dark structures within it in keeping with vascular flow voids (red arrow).

Images at time of presentation (a,b) show the lesion extends posteriorly into Meckel's cave which is bulky (arrow a) and from there to the level of the cavernous sinus (arrow b). Note that the cavernous segment of the left ICA is displaced slightly medially therefore it is difficult to assess true invasion of the cavernous sinus. On a later post-embolisation scan (c,d) the tumour has progressed at this site. The medial and lateral margins of the cavernous sinus are not clearly seen and tumour appears to lie within it. Note also prominent flow voids related to the cavernous segment of the ICA providing arterial supply to the tumour (arrow).

Left internal carotid cerebral angiogram (AP and lateral projections, (a and b)) showing that part of the tumour is supplied by branches from the cavernous segment of the internal carotid artery (arrow).