BACKGROUND: Management of intracranial epidural abscess (ICEA) typically requires a combination of surgical drainage and antibiotic therapy. However, the indications for neurosurgical drainage of ICEA have not been well established by evidence-based data and remain controversial. This article describes a case of ICEA that enlarged during antibiotic therapy but was managed successfully without neurosurgical drainage. OBSERVATIONS: A 13-year-old boy was admitted to the authors' hospital with a 6-day history of high fever, fatigue, and headache. Computed tomography and magnetic resonance imaging (MRI) revealed an ICEA in the right middle fossa with right-sided sinusitis. Initial empiric intravenous antibiotic therapy resulted in rapid improvement in clinical course. Despite clinical improvement, the abscess progressively enlarged by 158% after 2 weeks. Based on the patient's symptoms, age, and location of the lesion and considering the invasive surgical risks, neurosurgical drainage was not performed. Subsequently, the abscess began to decrease in size, and the patient was discharged after 5 weeks of hospitalization. Follow-up MRI at 6 months confirmed complete resolution of the abscess. LESSONS: Despite abscess enlargement, conservative management might be feasible when the patient demonstrates symptomatic improvement
thus, a tailored approach combining close monitoring with serial imaging is recommended. https://thejns.org/doi/10.3171/CASE24702.