eMedicine Specialties > Neurology > Neurological Infections

Intracranial Epidural Abscess: Differential Diagnoses & Workup

Author: Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Coauthor(s): Arun Ramachandran, State University of New York Upstate Medical University
Contributor Information and Disclosures

Updated: Sep 9, 2009

Differential Diagnoses

Bell Palsy
HIV-1 Associated Opportunistic Infections: CNS Toxoplasmosis
Cavernous Sinus Syndromes
Neurocysticercosis
Epidural Hematoma
Subarachnoid Hemorrhage
HIV-1 Associated Cerebrovascular Complications
Subdural Empyema
HIV-1 Associated CNS Conditions: Meningitis
HIV-1 Associated Opportunistic Infections: CNS Cryptococcosis

Other Problems to Be Considered

Central retinal artery occlusion
Delirium tremens
Encephalitis
Meningitis
Headache, cluster
Headache, migraine
Headache, tension
Neoplasms, brain
Tuberculoma of brain
Subdural empyema
Septic dural venous thrombosis
Brain abscess

Workup

Laboratory Studies

  • Findings from routine laboratory tests are not diagnostic but are essential in the preparation of the patient for operation. These tests may reveal polymorphonuclear (PMN) leukocytosis and an elevated erythrocyte sedimentation rate (ESR).
  • Results of blood cultures may be positive.
  • Hyponatremia has been reported in approximately 30% of cases.

Imaging Studies

  • Neuroimaging narrows the potential diagnoses and enables prompt empirical therapy until a specific microbiological diagnosis is made.
  • Radiography of the skull may demonstrate the responsible sinusitis, mastoiditis, or osteomyelitis.
  • Before the advent of CT scanning, cerebral angiography was often required. Cerebral angiography demonstrated an avascular mass that displaced the dural sinuses away from the inner table of the skull.
  • CT scanning of the brain without enhancement is often used as a screening tool in the assessment. Abscess appears as a poorly defined lentiform area of low or intermediate density (see Media file 1). CT scanning can also show bony destruction and fragmentation in patients with underlying mastoiditis. When contrast is administered, the convex inner side of the low-density lesion becomes enhanced and appears as rim enhancement caused by the inflamed dura.

    CT scan showing lenticular-shaped intracranial ep...

    CT scan showing lenticular-shaped intracranial epidural abscess.

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    CT scan showing lenticular-shaped intracranial ep...

    CT scan showing lenticular-shaped intracranial epidural abscess.

  • Because MRI is free from bony artifacts and easily demonstrates fluid collections outside the brain, it is the diagnostic procedure of choice to delineate a cranial epidural abscess.
  • Epidural fluid is observed as higher signal intensity than the ventricular cerebral spinal fluid (CSF) on both T1- and T2-weighted MRI. Use of gadolinium can significantly enhance the dura on T1-weighted MRI. MRI is also useful for visualizing small fluid collections that can be missed by CT scanning and in differentiating postoperative abscesses from hematomas or sterile effusions. MRI is particularly useful in differentiating subdural empyema from cranial epidural abscess. The characteristic MRI abnormality includes a crescentic or lentiform fluid collection overlying the hemisphere or in the interhemispheric fissure, which is mildly hyperintense relative to the CSF on T1-weighted images and isointense to CSF on T2-weighted images. A hypointense medial rim, representing the displaced dura is very characteristic of cranial epidural abscess.

    Intracranial epidural abscess. Enhanced MRI of th...

    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.

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    Intracranial epidural abscess. Enhanced MRI of th...

    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 ...

    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 (see Image 2).

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    Intracranial epidural abscess. A coronal section ...

    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 (see Image 2).



    Intracranial epidural abscess. MRI of the brain, ...

    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.

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    Intracranial epidural abscess. MRI of the brain, ...

    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.

  • The vein of Labbe may masquerade as an epidural abscess. Recognition of the vein of Labbe on CT scan is therefore essential for the appropriate management of otological and neurotological disease.

    Kraus et al present a 12-month-old male with acute coalescent mastoiditis and a subperiosteal abscess.10 An epidural abscess was suspected on preoperative CT scan. No abscess was found on surgery. Based on the surgical finding, they determined that this misdiagnosis was due to a vascular variant, the occipitotemporal vein (OTV, vein of Labbe) that masqueraded as an abscess on the CT scan. The OTV runs in an anterior-to-posterior direction along the lateral surface of the left temporal lobe and drains into the transverse sinus near its junction with the sigmoid sinus. It can be recognized on unenhanced MRIs as a prominent flow void apposed to the lateral aspect of the temporal lobe, and is readily demonstrated on MR and computed tomographic (CT) venographic images and on cerebral arteriograms obtained during the venous phase of enhancement.

Other Tests

Lumbar puncture carries the risk of precipitating herniation in the setting of increased ICP. Risks and benefits should be carefully weighed before a decision is made to proceed with a spinal tap. Findings on CSF studies can often be unremarkable, with reference range glucose and protein levels. CSF pressure may be increased. Spinal fluid may contain excess cells that are usually polymorphonuclear cells. The cell count is usually less than 200 cells, but it can be as high as 7000/mm3. Protein may be elevated as much as 100 mg/dL and the glucose level is often within the reference range unless associated meningitis is present, in which case it may be decreased.

More on Intracranial Epidural Abscess

Overview: Intracranial Epidural Abscess
Differential Diagnoses & Workup: Intracranial Epidural Abscess
Treatment & Medication: Intracranial Epidural Abscess
Follow-up: Intracranial Epidural Abscess
Multimedia: Intracranial Epidural Abscess
References
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Further Reading

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Keywords

epidural abscess, cranial epidural abscess, CEA, epidural empyema, patchy meningitis externa, increased intracranial pressure, ICP, intracranial infection, infection of the epidural space, epidural space infection

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Contributor Information and Disclosures

Author

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Arun Ramachandran, State University of New York Upstate Medical University
Arun Ramachandran is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ramon Diaz-Arrastia, MD, PhD, Assistant Professor, Department of Neurology, Comprehensive Epilepsy Center, University of Texas Southwestern
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, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
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