Preoperative embolization and stent placement in advanced juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a benign, rare, and highly vascular tumor. It is typically affecting young males. It arises from the pterygoid canal and could expand with destructive growth into the nasal cavity until skull base. The diagnosis of JNA is based on clinical and radiological examination. Digital subtraction angiography plays a crucial role in preoperative planning. The gold standard for the management of JNA is surgical removal. For advanced JNA, radiotherapy is known to be an effective treatment but it could induce long-term complications.

The patient, a 21-year-old male, reported symptoms of epistaxis one to 2 times per day, accompanied by nasal obstruction and headache. Gradually, his vision was blurred. The magnetic resonance imaging showed a mass in the pterygopalatine region extending and reaching intracranially to the temporal lobe. Angiography revealed a nasopharyngeal mass demonstrating tumor blush supplied by multiple feeders. The patient underwent two stages of embolization before surgery. The patient also gets an antiplatelet which is dilemmatic as we know that JNA is a hyper vascular tumor. That procedure significantly reduced the size of the tumor before surgery. Intraoperative bleeding was also notably less than expected.

This case underscores the challenges in managing advanced JNA, especially in the presence of intracranial extension and dual vascular supply. A two-stage embolization strategy, combined with selective coil embolization and preoperative stenting, proved to be a safe and effective approach in minimizing intraoperative bleeding, reducing size of the tumor, and facilitating complete tumor resection.