Half of Survivors of Cerebral Malaria Present With Cerebral Impairment After a Year

Computer enhanced false-colour Magnetic Resonance Images (MRI) of two mid-sagittal and one axial (cross sectional) sections through the head of a normal 46 year-old woman, showing structures of the brain, spine & facial tissues. Profiled features of the main part of the brain include the convoluted surface of the cerebral cortex, the corpus callosum, pons & medulla, structures of the brainstem, which are continuous with the spinal cord. The cerebellum, the centre of balance & coordination, lies to the right of the brainstem.
Researchers evaluated the incidence, course, and severity of neurodevelopmental impairments in survivors of cerebral malaria.

Impairments in development, cognition, and behavior after cerebral malaria (CM) among children in sub-Saharan Africa are highly prevalent, a new study found. The results from this study were published online in Pediatrics.

Children aged ≥6 months without a history of CM were enrolled from the Cognitive Outcomes and Psychiatric Symptoms of Retinopathy-Positive Cerebral Malaria study. At the time of enrollment, patients were discharged from a major public hospital in southern Malawi during peak malaria seasons of 2012 to 2014. Case patients admitted for retinopathy-positive CM had Plasmodium falciparum parasitemia, unarousable coma, and malaria retinopathy (n=85). A control group of patients admitted for nonneurologic conditions was also recruited (n=100).

Participants with CM underwent a neurologic examination, and patients aged <5 years were assessed at follow-up visits for gross motor, fine motor, language development, and social development. All patients were assessed at 1, 6, and 12 months, with caregiver interviews and standardized developmental, cognitive, and behavioral measures.

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Across all assessment periods, global development and cognition scores were lower for case patients vs control participants (0.73 standard deviation [SD] units; 95% CI, 0.47-0.98; P <.001). No change in global development and cognition were observed in case patients at each follow-up (mean slope, 0.00; 95% CI, −0.02 to 0.02). Likewise, the investigators found no changes in scores in the control group (mean slope, 0.00; 95% CI, −0.02 to 0.02).

At 12 months, developmental or cognitive impairment, as defined by global scores <10th percentile of the control sample, was found in 29% and 7% of case and control patients, respectively (odds ratio, 5.5; 95% CI, 2.3-13.6; P <.001). Scores on the Behavior Rating Inventory of Executive Function’s Inhibitory Self-Control Index were higher in case patients than control participants across follow-ups, indicating that cases had greater issues with inhibition and self-control (0.48 SD units; 95% CI, 0.12-0.84; P =.02). At 12 months, scores on the ISCI were still higher in cases vs control participants (0.49 SD units; 95% CI, 0.09-0.90; P <.01).

Enrollment of patients from a single country, as well as relying specifically on hospital-based patients for the control group, represented potential limitations of the study.

The findings from this study, according to the researchers, should ultimately “be used to encourage policy makers in malaria-endemic regions to prioritize directing resources to trials of acute interventions for preventing morbidity and to parental education, teacher training in special education, and rehabilitation programs for survivors of CM who are affected.”


Langfitt JT, McDermott MP, Brim R, et al. Neurodevelopmental impairments 1 year after cerebral malaria. Pediatrics. 2019;143(2):e20181026.