Medscape is available in 5 Language Editions – Choose your Edition here.


Intracranial Epidural Abscess Clinical Presentation

  • Author: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS; Chief Editor: Niranjan N Singh, MD, DM  more...
Updated: Nov 12, 2014


An intracranial epidural abscess often has an insidious onset, with symptoms developing over several weeks to months. Symptoms of the initiating infection might dominate the picture. Signs and symptoms are as follows:

  • Usually, the patient presents with headache that is either diffuse or localized to one side with scalp tenderness. Headache may be the only presenting symptom. The patient may have persistent fever that develops during or after treatment for sinus or middle ear infection. Purulent discharge from the ears or sinuses, periorbital swelling, and brawny edema of the scalp might accompany.
  • Because the epidural abscess usually enlarges slowly, the following signs do not develop until the infection has reached the subdural space, resulting in subdural empyema, at which time the patient might present with neck stiffness, nausea, vomiting, lethargy, and hemiparesis. Seizures might very well be the first presenting symptom in some cases.
  • Symptoms and signs of increased intracranial pressure (ICP) include nausea, vomiting, and papilledema. Rarely, when the epidural abscess develops near the petrous bone and involves the fifth and sixth cranial nerves, the patient may present with ipsilateral facial pain and weakness of the lateral rectus muscle (ie, the so-called Gradenigo syndrome). Many times, scalp cellulitis, sinusitis, or skull fracture may draw the attention of the physician to such an extent that the diagnosis of epidural abscess may be missed.
  • One should consider the diagnosis of intracranial epidural abscess when a patient presents with unresolving frontal sinus symptoms. Also consider this diagnosis in patients with new neurologic symptoms after trauma or cranial surgery, even if months or years have elapsed since operation or trauma.
  • Onset can be acute, especially in patients without any history of previous cranial neurosurgery. They often present with acute symptoms of encephalopathy and focal neurological deficits.
  • Mittal et al present the case of an 11-year-old girl who presented with typical features of meningitis, suggesting that sinusitis can rarely be latent and present directly with intracranial complications. She underwent neuroimaging because of slow improvement and concern for a brain abscess. Although no history or examination findings were suggestive of sinusitis, the patient was found to have pansinusitis with intracranial extension causing meningitis and epidural abscess. [9]


Because the intracranial epidural space is only a potential space and the dura is essentially adherent to the inner table of the skull, infection in the epidural space can result from the following:

Sinusitis (mastoid, ethmoid, sphenoid, and frontal sinusitis); trauma associated with skull fracture; and following craniotomy, orbital cellulitis, cranial osteomyelitis, sagittal sinus phlebitis, fetal monitoring, and mucormycosis.[10]

The risk of infection is increased when multiple neurosurgical operations are performed or if the operation also involves implantation of foreign material. Even though hematogenous spread to the epidural space from a remote site of infection is a common cause of spinal epidural abscess, it is a rare cause of cranial epidural abscess.

Mallur et al reported on 11 children with acute mastoiditis. Complications in these children were as follows: 4 cases of cranial epidural abscess, 4 cases of sigmoid sinus thrombosis, 2 cases of perisigmoid abscess or bony erosion, and 1 case of tegmen mastoideum dehiscence). The authors claim that, although uncommon, intracranial complications of acute mastoiditis may present without clinical signs or symptoms. Computed tomography of the temporal bone with contrast is essential for identifying asymptomatic complications.[11]


Epidural abscess usually occurs as a result of infection caused by Staphylococcus aureus, Staphylococcus epidermidis, enteric gram-negative bacilli (especially Escherichia coli), Pseudomonas species, Bacteroides species, and other anaerobes. Aerobic and microaerophilic streptococci are usually responsible for infection that has spread from the paranasal sinuses. Rarely, Salmonella species, Eikenella corrodens, and Mucor species have been isolated. Haemophilus influenzae may also be the responsible organism, in addition to Mycobacterium tuberculosis, Proteus penneri, Actinomyces species, Blastomyces species, Aspergillus fumigatus, and Cladosporium species.

Contributor Information and Disclosures

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.


Arun Ramachandran, MD State University of New York Upstate Medical University

Arun Ramachandran, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Ramon Diaz-Arrastia, MD, PhD Professor, Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Director, North Texas TBI Research Center, Comprehensive Epilepsy Center, Parkland Memorial Hospital

Ramon Diaz-Arrastia, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, New York Academy of Sciences, Phi Beta Kappa

Disclosure: Nothing to disclose.

  1. Bleck TP, Greenlee JE. Mandell GL, et al. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone; 2000. 1028-1031.

  2. Yildirmak T, Gedik H, Simsek F, Kantürk A. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int. 2014. 5:142. [Medline]. [Full Text].

  3. Britton CB. Infections of the nervous system complicating alcoholism and illicit drug use. Continuum: Lifelong Learning in Neurology. 2004 Oct. 5:48-76.

  4. Erman T, Demirhindi H, Göçer AI, Tuna M, Ildan F, Boyar B. Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis. Surg Neurol. 2005 Feb. 63(2):107-12; discussion 112-3. [Medline].

  5. Korinek AM, Golmard JL, Elcheick A, Bismuth R, van Effenterre R, Coriat P. Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg. 2005 Apr. 19(2):155-62. [Medline].

  6. Harris LF, Haws FP, Triplett JN Jr, Maccubbin DA. Subdural empyema and epidural abscess: recent experience in a community hospital. South Med J. 1987 Oct. 80(10):1254-8. [Medline].

  7. Germiller JA, Monin DL, Sparano AM, Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg. 2006 Sep. 132(9):969-76. [Medline].

  8. Woods CR Jr. Brain abscess and other intracranial suppurative complications. Adv Pediatr Infect Dis. 1995. 10:41-79. [Medline].

  9. Mittal MK, Zimmerman RA. Meningitis and epidural abscess related to pansinusitis. Pediatr Emerg Care. 2009 Apr. 25(4):267-8. [Medline].

  10. Seto T, Takesada H, Matsushita N, Ishibashi K, Tsuyuguchi N, Shimono T, et al. Twelve-year-old girl with intracranial epidural abscess and sphenoiditis. Brain Dev. 2014 Apr. 36(4):359-61. [Medline].

  11. Mallur PS, Harirchian S, Lalwani AK. Preoperative and postoperative intracranial complications of acute mastoiditis. Ann Otol Rhinol Laryngol. 2009 Feb. 118(2):118-23. [Medline].

  12. Kraus M, Shelef I, Niv A, Kaplan DM. The vein of Labbe masquerading as an epidural abscess. J Laryngol Otol. 2007 Aug. 121(8):e12. [Medline].

  13. Noggle JC, Sciubba DM, Nelson C, Garcés-Ambrossi GL, Ahn E, Jallo GI. Supraciliary keyhole craniotomy for brain abscess debridement. Neurosurg Focus. 2008. 24(6):E11. [Medline].

  14. Eviatar E, Lavi R, Fridental I, Gavriel H. Endonasal endoscopic drainage of frontal lobe epidural abscess. Isr Med Assoc J. 2008 Mar. 10(3):239-40. [Medline].

  15. Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol. 2009 Mar. 8(3):292-300. [Medline].

  16. Akova M, Akalin HE, Korten V, et al. Treatment of intracranial abscesses: experience with sulbactam/ampicillin. J Chemother. 1993 Jun. 5(3):181-5. [Medline].

  17. Ariza J, Casanova A, Fernandez Viladrich P, et al. Etiological agent and primary source of infection in 42 cases of focal intracranial suppuration. J Clin Microbiol. 1986 Nov. 24(5):899-902. [Medline].

  18. Bizakis JG, Velegrakis GA, Papadakis CE, et al. The silent epidural abscess as a complication of acute otitis media in children. Int J Pediatr Otorhinolaryngol. 1998 Oct 2. 45(2):163-6. [Medline].

  19. Brook I, Friedman EM. Intracranial complications of sinusitis in children. A sequela of periapical abscess. Ann Otol Rhinol Laryngol. 1982 Jan-Feb. 91(1 Pt 1):41-3. [Medline].

  20. Cohen AR, Gupta N. Mass in the forehead of a three-year-old girl. Pediatr Neurosurg. 2002 Jul. 37(1):38-47. [Medline].

  21. Coyne TJ, Kemp RJ. Intracranial epidural abscess: a report of three cases. Aust N Z J Surg. 1993 Feb. 63(2):154-7. [Medline].

  22. Daniels LK. Rapid in-office and in-vivo desensitization of an injection phobia utilizing hypnosis. Am J Clin Hypn. 1976 Jan. 18(3):200-3. [Medline].

  23. Durand B, Poje C, Dias M. Sinusitis-associated epidural abscess presenting as posterior scalp abscess--a case report. Int J Pediatr Otorhinolaryngol. 1998 Mar 1. 43(2):147-51. [Medline].

  24. Efird T, Ram S, Neitzschman HR. Radiology case of the month. Chronic headache after trauma. Intracranial epidural abscess. J La State Med Soc. 2004 Jan-Feb. 156(1):12-4. [Medline].

  25. Fountas KN, Duwayri Y, Kapsalaki E, et al. Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature. South Med J. 2004 Mar. 97(3):279-82; quiz 283. [Medline].

  26. Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope. 1998 Nov. 108(11 Pt 1):1635-42. [Medline].

  27. Gil-Carcedo LM, Izquierdo JM, Gonzalez M. Intracranial complications of frontal sinusitis. A report of two cases. J Laryngol Otol. 1984 Sep. 98(9):941-5. [Medline].

  28. Gower D, McGuirt WF. Intracranial complications of acute and chronic infectious ear disease: a problem still with us. Laryngoscope. 1983 Aug. 93(8):1028-33. [Medline].

  29. Green HT, O'Donoghue MA, Shaw MD, Dowling C. Penetration of ceftazidime into intracranial abscess. J Antimicrob Chemother. 1989 Sep. 24(3):431-6. [Medline].

  30. Harrison MJ. The clinical presentation of intracranial abscesses. Q J Med. 1982. 51(204):461-8. [Medline].

  31. Hirschberg H, Bosnes V. C-reactive protein levels in the differential diagnosis of brain abscesses. J Neurosurg. 1987 Sep. 67(3):358-60. [Medline].

  32. Hlavin ML, Kaminski HJ, Fenstermaker RA, White RJ. Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery. 1994 Jun. 34(6):974-80; discussion 980-1. [Medline].

  33. Ildan F, Gursoy F, Gul B, et al. Intracranial tuberculous abscess mimicking malignant glioma. Neurosurg Rev. 1994. 17(4):317-20. [Medline].

  34. Johnson DL, Markle BM, Wiedermann BL, Hanahan L. Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr. 1988 Jul. 113(1 Pt 1):15-23. [Medline].

  35. Kamiya K, Inagawa T. Huge calcified epidural abscess--case report. Neurol Med Chir (Tokyo). 1990 Jul. 30(7):495-7. [Medline].

  36. Kaufman DM, Leeds NE. Computed tomography (CT) in the diagnosis of intracranial abscesses. Brain abscess, subdural empyema, and epidural empyema. Neurology. 1977 Nov. 27(11):1069-73. [Medline].

  37. Lefkowitz MA, Chin LS, Couldwell WT. Pediatric intracranial epidural abscess secondary to an infected scalp vein catheter. Pediatr Neurosurg. 1998 Dec. 29(6):297-9. [Medline].

  38. Lerner DN, Choi SS, Zalzal GH, Johnson DL. Intracranial complications of sinusitis in childhood. Ann Otol Rhinol Laryngol. 1995 Apr. 104(4 Pt 1):288-93. [Medline].

  39. Letscher V, Herbrecht R, Gaudias J, et al. Post-traumatic intracranial epidural Aspergillus fumigatus abscess. J Med Vet Mycol. 1997 Jul-Aug. 35(4):279-82. [Medline].

  40. Mammen-Prasad E, Murillo JL, Titelbaum JA. Infectious disease rounds: Pott's puffy tumor with intracranial complications. N J Med. 1992 Jul. 89(7):537-9. [Medline].

  41. Miller ES, Dias PS, Uttley D. CT scanning in the management of intracranial abscess: a review of 100 cases. Br J Neurosurg. 1988. 2(4):439-46. [Medline].

  42. Morioka T, Fujiwara S, Akimoto T, et al. Intracranial epidural abscess: late complication of allograft cranioplasty. Fukuoka Igaku Zasshi. 1996 Feb. 87(2):57-9. [Medline].

  43. Nathoo N, Nadvi SS, van Dellen JR. Cranial extradural empyema in the era of computed tomography: a review of 82 cases. Neurosurgery. 1999 Apr. 44(4):748-53; discussion 753-4. [Medline].

  44. Norrell HA Jr, Wilson CB. Primary intracranial extradural abscess diagnosed by carotid angiography. J Ky Med Assoc. 1967 Dec. 65(12):1186-87+. [Medline].

  45. Papo I, Perria C, Carai M, et al. The surgical treatment of intracranial abscesses today. Zentralbl Neurochir. 1989. 50(1):34-8. [Medline].

  46. Parker GS, Tami TA, Wilson JF, Fetter TW. Intracranial complications of sinusitis. South Med J. 1989 May. 82(5):563-9. [Medline].

  47. Pascual J, Diez C, Carda JR, Vazquez-Barquero A. Intraventricular haemorrhage complicating a brain abscess. Postgrad Med J. 1987 Sep. 63(743):785-7. [Medline].

  48. Rath SA, Knoringer P. Late brain abscess years after severe cerebrocranial trauma with fronto-orbitobasal fracture. Childs Nerv Syst. 1989 Apr. 5(2):121-3. [Medline].

  49. Reader ME, Eliachar I, McIntire LD, Hahn J. Frontal sinusitis with chronic epidural abscess: a case presentation. Ear Nose Throat J. 1992 Nov. 71(11):599-603. [Medline].

  50. Rosenfeld EA, Rowley AH. Infectious intracranial complications of sinusitis, other than meningitis, in children: 12-year review. Clin Infect Dis. 1994 May. 18(5):750-4. [Medline].

  51. Savitz MH, Dickinson T. Drug therapy for intracranial suppuration. Am Fam Physician. 1988 Feb. 37(2):341-4. [Medline].

  52. Schliamser SE, Backman K, Norrby SR. Intracranial abscesses in adults: an analysis of 54 consecutive cases. Scand J Infect Dis. 1988. 20(1):1-9. [Medline].

  53. Sellick JA Jr. Epidural abscess and subdural empyema. J Am Osteopath Assoc. 1989 Jun. 89(6):806-10. [Medline].

  54. Sharif HS, Ibrahim A. Intracranial epidural abscess. Br J Radiol. 1982 Jan. 55(649):81-4. [Medline].

  55. Smith HP, Hendrick EB. Subdural empyema and epidural abscess in children. J Neurosurg. 1983 Mar. 58(3):392-7. [Medline].

  56. Weiner GM, Williams B. Prevention of intracranial problems in ear and sinus surgery: a possible role for cefotaxime. J Laryngol Otol. 1993 Nov. 107(11):1005-7. [Medline].

  57. Weingarten K, Zimmerman RD, Becker RD, et al. Subdural and epidural empyemas: MR imaging. AJR Am J Roentgenol. 1989 Mar. 152(3):615-21. [Medline].

  58. Wenig BL, Goldstein MN, Abramson AL. Frontal sinusitis and its intracranial complications. Int J Pediatr Otorhinolaryngol. 1983 Jul. 5(3):285-302. [Medline].

  59. Woods CR Jr. Brain abscess and other intracranial suppurative complications. Adv Pediatr Infect Dis. 1995. 10:41-79. [Medline].

CT scan showing lenticular-shaped intracranial epidural abscess.
Intracranial epidural abscess. Enhanced MRI of the brain, axial section, revealing a left temporal epidural abscess with an abscess cavity and a thickened enhancing capsule. Adjacent thickened dura enhances as well. In addition, mass effect is evident.
Intracranial epidural abscess. A coronal section of the MRI revealing a left temporal epidural abscess with an abscess cavity and a thickened enhancing capsule. Adjacent thickened dura enhances as well. In addition, mass effect is evident.
Intracranial epidural abscess. MRI of the brain, unenhanced. A T1-weighted image (axial view) showing a left temporal epidural abscess with an abscess cavity, surrounding capsule, and the thickened dura underneath. Mass effect is evident.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.