Intracranial epidural abscess
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
- John H Sampson, MD, PhD, MBA
John H Sampson, MD, PhD, MBA
- Robert H. and Gloria Wilkins Distinguished Professor of Neurosurgery
- Professor of Biomedical Engineering, Immunology, and Pathology
- Chair, Department of Neurosurgery
- Duke University Medical Center
Epidural abscess is a rare but important suppurative infection of the central nervous system (CNS) . Abscesses that are enclosed within the bony confines of the skull or spinal column can expand to compress the brain or spinal cord and cause severe symptoms, permanent complications, or even death. Prompt diagnosis and proper treatment can avert complications and achieve cure in many cases. Both the diagnosis and management of epidural abscess, which often includes a surgical procedure for aspiration or drainage of the abscess, have been greatly aided by the advent of modern imaging techniques, such as computed tomography (CT) and especially magnetic resonance imaging (MRI) [2-4].
Two distinct varieties of epidural abscess occur: spinal epidural abscess (SEA) and intracranial epidural abscess (IEA). SEA is more common by a factor of nine to one. The distinction between these two entities is based upon the different anatomy of the two locations within the CNS and some differences in symptoms and natural history. Intracranial epidural abscesses (IEAs) are less common than spinal epidural abscess (SEAs) and less acute in their evolution. However, like SEAs, IEAs are significant infections requiring optimal therapy to prevent complications.
The epidemiology, microbiology, clinical manifestations, diagnosis, and treatment of IEA will be reviewed here. SEA, brain abscess, and bacterial meningitis are discussed separately. (See "Spinal epidural abscess" and "Pathogenesis, clinical manifestations, and diagnosis of brain abscess" and "Treatment and prognosis of bacterial brain abscess" and "Epidemiology of bacterial meningitis in adults" and "Pathogenesis and pathophysiology of bacterial meningitis" and "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults" and "Neurologic complications of bacterial meningitis in adults".)
The intracranial dura mater forms the inner lining of the skull and is directly adherent to bone. Thus, under normal circumstances, there is no actual epidural space. The potential epidural space can be opened by pressure from expanding tumors, blood, inflammatory masses, or pus. This requires that the firmly adherent dura be dissected off the bone; as a result, intracranial epidural abscesses tend to be slow growing, rounded, and well localized.
PATHOGENESIS AND PATHOLOGY
Organisms usually spread into the potential extradural space by direct extension from a contiguous focus of infection or by inoculation during trauma or neurosurgery. Organisms may also pass through the venous foramina of the frontal bone plate to this space without causing frontal bone osteomyelitis. After reaching this site, the bacteria cause inflammation and the formation of pus or granulation tissue, which gradually dissect the tough and adherent dura away from the inner table of the skull.
- Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.
- Danner RL, Hartman BJ. Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987; 9:265.
- Nussbaum ES, Rigamonti D, Standiford H, et al. Spinal epidural abscess: a report of 40 cases and review. Surg Neurol 1992; 38:225.
- Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol 2009; 8:292.
- Heran NS, Steinbok P, Cochrane DD. Conservative neurosurgical management of intracranial epidural abscesses in children. Neurosurgery 2003; 53:893.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Pfausler B, Spiss H, Beer R, et al. Treatment of staphylococcal ventriculitis associated with external cerebrospinal fluid drains: a prospective randomized trial of intravenous compared with intraventricular vancomycin therapy. J Neurosurg 2003; 98:1040.
- Jorgenson L, Reiter PD, Freeman JE, et al. Vancomycin disposition and penetration into ventricular fluid of the central nervous system following intravenous therapy in patients with cerebrospinal devices. Pediatr Neurosurg 2007; 43:449.
- Wang Q, Shi Z, Wang J, et al. Postoperatively administered vancomycin reaches therapeutic concentration in the cerebral spinal fluid of neurosurgical patients. Surg Neurol 2008; 69:126.
- Nau R, Prange HW, Menck S, et al. Penetration of rifampicin into the cerebrospinal fluid of adults with uninflamed meninges. J Antimicrob Chemother 1992; 29:719.
- Perlroth J, Kuo M, Tan J, et al. Adjunctive use of rifampin for the treatment of Staphylococcus aureus infections: a systematic review of the literature. Arch Intern Med 2008; 168:805.
- von Specht M, Gardella N, Tagliaferri P, et al. Methicillin-resistant Staphylococcus aureus in community-acquired meningitis. Eur J Clin Microbiol Infect Dis 2006; 25:267.
- Pintado V, Meseguer MA, Fortún J, et al. Clinical study of 44 cases of Staphylococcus aureus meningitis. Eur J Clin Microbiol Infect Dis 2002; 21:864.
- Gallagher RM, Pizer B, Ellison JA, Riordan FA. Glycopeptide insensitive Staphylococcus aureus subdural empyema treated with linezolid and rifampicin. J Infect 2008; 57:410.
- Kessler AT, Kourtis AP. Treatment of meningitis caused by methicillin-resistant Staphylococcus aureus with linezolid. Infection 2007; 35:271.
- Naesens R, Ronsyn M, Druwé P, et al. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol 2009; 58:1247.
- Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007; 41:296.
- Levitz RE, Quintiliani R. Trimethoprim-sulfamethoxazole for bacterial meningitis. Ann Intern Med 1984; 100:881.
- Vartzelis G, Theodoridou M, Daikos GL, et al. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005; 33:36.
- Lee DH, Palermo B, Chowdhury M. Successful treatment of methicillin-resistant staphylococcus aureus meningitis with daptomycin. Clin Infect Dis 2008; 47:588.
- Wallace WR, Sander AW, Licitra C, et al. Methicillin-resistant Staphylococcus aureus meningitis successfully treated with daptomycin. Infect Dis Clin North Am 2009; 17:69.
- Nathoo N, Nadvi SS, van Dellen JR. Cranial extradural empyema in the era of computed tomography: a review of 82 cases. Neurosurgery 1999; 44:748.