Intracranial Epidural Abscess Treatment & Management

Updated: Jan 03, 2018
  • Author: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Medical Care

Early diagnosis and treatment of epidural abscess cannot be overemphasized as neurologic outcome mainly depends on the patient’s neurologic status immediately prior to surgery.

Prehospital management

Rapid transport and early stabilization are highly essential in the prehospital setting.

Endotracheal intubation and hyperventilation may be required in some patients who are critically ill.

Initial management

This depends upon the type of clinical presentation.

The presence of seizures and focal neurological deficits requires emergent intubation, anticonvulsant therapy, hyperventilation, and hemodynamic stabilization before proceeding with diagnostic tests.

Patients who are not critically ill or who have a subtle presentation may undergo CT scanning after initial clinical evaluation. Neurologic status should be monitored closely.

Antibiotic therapy

Until the culture and sensitivity report of the infectious agent becomes available, the choice of empiric antibiotic therapy should be based on the underlying etiology. For example, when an intracranial abscess is thought to be due to extension of infection from paranasal sinuses involving staphylococcal, aerobic, and anaerobic bacteria, more than one antibiotic is necessary. Likewise, an antistaphylococcal agent would be an appropriate choice for infection occurring after a neurosurgical procedure.

For patients presenting in the emergency department (ED) with cranial epidural abscess, empirical antibiotics are the first-line pharmacologic therapy. These antibiotics must cover a broad spectrum of both aerobic and anaerobic bacterial organisms.

Usually, length of therapy is determined by the patient's response to treatment and by resolution of the epidural abscess on follow-up MRI and/or CT scanning. As a general rule, antibiotic therapy should be continued for a minimum of 8 weeks if surgery is not undertaken and for at least 4 weeks if the abscess is drained. Antibiotics have been administered from 6 weeks to 6 months. In general, follow-up CT scanning or MRI should be obtained 10–14 days after antibiotic therapy has been discontinued.

Seizure therapy

Prophylactic seizure therapy is not generally recommended. If cranial epidural abscess is not associated with subdural empyema, seizures are unlikely to ensue. In the event of the administration of anticonvulsant therapy, consider weaning patients off anticonvulsant therapy if patients remain seizure free for more than 2 years and the EEG findings do not show any evidence of seizure disorder.

Discontinuing anticonvulsant therapy suddenly can be risky because it can lead to recurrent seizures, which may be prolonged. This is true even if the medication was not successfully controlling the seizures. Weaning patients off the drug gradually after fully understanding the potential possibility of recurrent seizure(s) and related consequences, including losing a driving license and the possible impact on employment, is strongly advised. If seizures do recur, resuming the previous medication immediately usually results in the same level of seizure control as before. However, in rare instances, the original antiepileptic medication may not be as effective, even if previously successful; alternative therapy should be considered.


Surgical Care

Surgical intervention is an integral part of treatment for epidural abscesses in patients with neurologic symptoms or who have not responded to medical management.

Optimal management of an intracranial epidural abscess should include neurosurgical drainage; Gram stain, India ink, and acid-fast bacilli (AFB) staining of the purulent material; and administration of appropriate intravenous antibiotic(s). In case of small abscesses, adequate appropriate antibiotic therapy alone might suffice, without the need for surgical intervention.

The goal of therapy is to eradicate the infection and prevent further complications. Surgical exploration, decompression, and debridement, along with antibiotic therapy, are the mainstays of surgical treatment in cranial epidural abscess.

The type of emergency surgery for cranial epidural abscess depends on the extent of the lesion and involvement of the overlying skull bone.

  • When burr holes cannot provide sufficient drainage or when debridement with drainage is indicated, craniotomy is undertaken.

  • When the dura is affected by infection, a dural graft may be required. During anesthesia, anesthetics that can cause intracranial vasodilation should be avoided because this might result in further increase in intracranial pressure, heralding herniation.

Noggle et al report that frontal, supraorbital epidural abscesses of the anterior and middle cranial fossa can be adequately and safely debrided via a minimally invasive supraciliary craniotomy. This approach has a cosmetic benefit and may decrease approach-related morbidity. [14]

Eviator et al. recommend that in cases of epidural abscess secondary to sinusitis that are located in the anterior base of the skull, draining the abscess endoscopically via nasal space may be considered by an experienced surgeon. This is minimally invasive, particularly so when osteomyelitis and other anatomical abnormalities of the skull exist. [15]

In a study comparing functional outcomes of acute inpatient rehabilitation for spinal epidural abscess (SEA) patients with and without history of intravenous substance abuse (IVSA), researchers found no significant differences between the 2 groups. They further concluded that acute inpatient rehabilitation can effectively improve functional outcomes in SEA patients with or without IVSA, even though these 2 patient groups can vary in clinical factors. [16]



Immediate neurosurgical consultation is highly warranted.

A multidisciplinary approach involving an otolaryngologist may be necessary if the patient presents with concurrent paranasal sinusitis.