The management of large juvenile nasopharyngeal angiofibromas with intracranial extension is controversial. We review our experience since 1980 with eighteen patients with juvenile nasopharyngeal angiofibroma. A diagnostic and treatment approach consisting of preoperative magnetic resonance imaging, embolization of feeding branches from the external carotid artery, and attempted complete resection was used in seven patients with intracranial disease since 1987. Serial magnetic resonance images were used for followup. Intracranial disease that was persistent or recurrent and demonstrated subsequent growth was irradiated (35 to 45 cGy). Extracranial tumor recurrences were reexcised. We advocate this approach as a safe and effective alternative to primary irradiation and its sequelae.