Acute Brain MRI Findings in 120 Malawian Children with Cerebral Malaria: New Insights into an Ancient Disease

Cortical abnormalities. Examples of cortical abnormalities seen in ret+ CM on axial T2 FSE images. Cortical abnormalities were relatively confluent in some cases as seen in a boy 2 years 11 month of age (A), in whom all the visualized gray matter has increased T2 signal intensity and is diffusely thickened (>5 mm). The cortical abnormalities were distinctly multifocal in others as seen in a girl of 6 years 8 month of age (B), in whom there are patchy areas of involvement and areas of relative sparing. In most cases, the signal-intensity abnormalities and cortical thickening were not confined to typical arterial vascular distributions.

Patterns of cortical involvement. The patterns of affected cortical parenchyma generally fell into 1 of 3 distinct types as seen on the EPI DWI images: 1) diffuse; 2) posterior predominance, as is illustrated in a girl of 1 year 3 months of age (A); and 3) frontal predominance, as evident in a girl 3 years 6 months of age (B).

Asymmetric hemispheric cortical involvement. Occasionally markedly asymmetric hemispheric cortical involvement was evident. The cortical involvement tended to be confluent and associated with DWI abnormalities such as in an axial T2 FSE (A) and an axial EPI DWI in a girl, 2 years 7 months of age (B). Another example is seen in an axial T2 FSE (C), and an axial EPI DWI (D) in a boy 1 year 11 months of age. Note the associated midline shift. These patients also illustrate how children with CM frequently have constellations of findings seen in ret+ CM but, by no means are all in the same patients at the same time. For example, A and B above have subcortical white matter sparing on the T2 images, while in C and D, no subcortical white matter was involved. Also note how A and B show positive restricted diffusion in the right hemispheric white matter on the DWI images in the absence of significantly high T2 signal-intensity changes.

Distribution of white matter changes. There were 2 distinct patterns of white matter involvement: 1) primarily subcortical (A), a coronal T2 FSE in a boy 1 year 6 months of age; and 2) primarily peritrigonal (B), a coronal T2 FSE in a girl 2 years 6 months of age. These frequently coexisted, but subcortical involvement predominated.

White matter DWI abnormalities. Subcortical white matter changes had corresponding positive DWI findings, which tended to closely follow theT2 signal-intensity abnormalities. The restricted diffusion was generally confluent and not associated with positive cortical DWI findings. We present 2 representative cases: an axial T2 FSE (A) and an axial EPI DWI (B) in a 7-year-old boy.