Intracranial pressure in African children with cerebral malaria

doi:10.1016/0140-6736(91)91638-B

The Lancet

Volume 337, Issue 8741, 9 March 1991, Pages 573-576

https://doi.org/10.1016/0140-6736(91)91638-B Get rights and content

Abstract

Opening lumbar cerebrospinal fluid (CSF) pressure was measured with a paediatric spinal fluid manometer in 26 of 61 Kenyan children (mean age 39 months) with cerebral malaria. In all cases pressure was above normal (mean [SD] 22·6 [7·4] cm CSF, range 10·5-36). Clinical features of our patients suggest that intracranial hypertension is important in the pathogenesis of cerebral malaria in children, especially as a cause of death. We suggest that raised intracranial pressure is secondary to increased cerebral blood volume. Lowering intracranial pressure may significantly reduce the mortality and morbidity of cerebral malaria. The potential risks and benefits of lumbar puncture should be considered carefully in patients with suspected cerebral malaria.

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Citation Excerpt :
Some children with cerebral malaria have clinical signs consistent with brain-stem compromise as a result of raised intracranial pressure.12 Increased intracranial pressure, measured directly, has been observed in children with cerebral malaria,12,23 and in one study, CT scans showed increased brain volumes in 6 of 14 children.24 At the time of those previous studies, the importance of retinopathy status was not known, and all the children underwent scanning more than 40 hours after admission, which may have been too late to identify brain swelling.
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We enrolled children who met a stringent definition of cerebral malaria (one that included the presence of retinopathy), characterized them in detail clinically, and obtained MRI scans on admission and daily thereafter while coma persisted.
Of 348 children admitted with cerebral malaria (as defined by the World Health Organization), 168 met the inclusion criteria, underwent all investigations, and were included in the analysis. A total of 25 children (15%) died, 21 of whom (84%) had evidence of severe brain swelling on MRI at admission. In contrast, evidence of severe brain swelling was seen on MRI in 39 of 143 survivors (27%). Serial MRI scans showed evidence of decreasing brain volume in the survivors who had had brain swelling initially.
Increased brain volume was seen in children who died from cerebral malaria but was uncommon in those who did not die from the disease, a finding that suggests that raised intracranial pressure may contribute to a fatal outcome. The natural history indicates that increased intracranial pressure is transient in survivors. (Funded by the National Institutes of Health and Wellcome Trust U.K.)
Malaria causes substantial morbidity and mortality in sub-Saharan Africa. In this report from Malawi, the pathogenesis of cerebral malaria in children is evaluated.
Despite recent advances in treatment, prevention, and control, malaria remains a major scourge.¹ Quinine, the mainstay of treatment for cerebral malaria for 300 years, has been supplanted by artesunate,2, 3 but despite more rapid parasite clearance with artesunate, the case fatality rate among African children with cerebral malaria treated with artesunate remains high at 18%.³ Improvements in community-based care will help to prevent cerebral malaria, but additional advances in the treatment of hospitalized patients will probably require adjunctive therapies targeting key pathogenetic mechanisms.
The pathogenesis of cerebral malaria is incompletely understood, and although there is considerable evidence to suggest that . . .

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ORIGINAL ARTICLESIntracranial pressure in African children with cerebral malaria

Abstract

Prog Brain Res

Trans R Soc Trop Med Hyg

Lancet

Lancet

Lancet

Lancet

Severe and complicated malaria

Trans R Soc Trop Med Hyg

Clinical features and prognostic indicators in paediatric cerebral malaria: a study of 131 comatose Malawian children

QJ Med

Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries

J Neurosurg

Cerebrospinal fluid pressure in pyogenic meningitis

Arch Dis Child

Transcranial pulsed Doppler ultrasound findings in brain stem death

J Neurol Neurosurg Psychiatry

ORIGINAL ARTICLES
Intracranial pressure in African children with cerebral malaria