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Intracranial Epidural Abscess Workup

  • 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
 

Laboratory Studies

See the list below:

  • 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.
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Imaging Studies

See the list below:

  • 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 the image below). 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 epiCT 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. See the images below.
    Intracranial epidural abscess. Enhanced MRI of theIntracranial 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 oIntracranial 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, uIntracranial 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.[12] 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.
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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.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

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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.
 
 
 
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