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Magnetic resonance imaging of the brain in adults with severe falciparum malaria

Richard James Maude123*, Frederik Barkhof4, Mahtab Uddin Hassan5, Aniruddha Ghose5, Amir Hossain5, M Abul Faiz67, Ehsan Choudhury8, Rehnuma Rashid5, Abdullah Abu Sayeed5, Prakaykaew Charunwatthana2, Katherine Plewes2, Hugh Kingston129, Rapeephan Rattanawongnara Maude2, Kamolrat Silamut2, Nicholas Philip John Day12, Nicholas John White12 and Arjen Mattheus Dondorp12

Author Affiliations

1 Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 7LJ, UK

2 Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Rajthevee, Bangkok 10400, Thailand

3 College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK

4 Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, The Netherlands

5 Chittagong Medical College Hospital, Chittagong, Bangladesh

6 Dev Care Foundation, Dhaka, Bangladesh

7 Center for Specialized Care and Research, Chittagong, Bangladesh

8 Chevron Laboratory, Chittagong, Bangladesh

9 Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia

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Malaria Journal 2014, 13:177  doi:10.1186/1475-2875-13-177

Published: 9 May 2014

Abstract

Background

Magnetic resonance imaging (MRI) allows detailed study of structural and functional changes in the brain in patients with cerebral malaria.

Methods

In a prospective observational study in adult Bangladeshi patients with severe falciparum malaria, MRI findings in the brain were correlated with clinical and laboratory parameters, retinal photography and optic nerve sheath diameter (ONSD) ultrasound (a marker of intracranial pressure).

Results

Of 43 enrolled patients, 31 (72%) had coma and 12 (28%) died. MRI abnormalities were present in 79% overall with mostly mild changes in a wide range of anatomical sites. There were no differences in MRI findings between patients with cerebral and non-cerebral or fatal and non-fatal disease. Subtle diffuse cerebral swelling was common (n = 22/43), but mostly without vasogenic oedema or raised intracranial pressure (ONSD). Also seen were focal extracellular oedema (n = 11/43), cytotoxic oedema (n = 8/23) and mildly raised brain lactate on magnetic resonance spectroscopy (n = 5/14). Abnormalities were much less prominent than previously described in Malawian children. Retinal whitening was present in 36/43 (84%) patients and was more common and severe in patients with coma.

Conclusion

Cerebral swelling is mild and not specific to coma or death in adult severe falciparum malaria. This differs markedly from African children. Retinal whitening, reflecting heterogeneous obstruction of the central nervous system microcirculation by sequestered parasites resulting in small patches of ischemia, is associated with coma and this process is likely important in the pathogenesis.

Keywords:
MRI; Falciparum; Cerebral; Retinopathy; Pathophysiology