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

Abstract

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

Dynamic interactions ofPlasmodiumspp. with vascular endothelium

“…25 Brain herniation is not seen, nor is there evidence of toxigenic or vasogenic edema. 21 This would be in keeping with a lack of detection of albumin or IgG leakage into the CSF of adult patients with CM, in contrast to the significant leakage seen during bacterial meningitis. 19 More importantly, none of the MRI findings are different between patients with cerebral and non-cerebral malaria, and there are no differences between fatal and nonfatal infections.…”

“…21,24 Mild diffuse brain swelling is found in a variety of anatomical sites. This swelling is partly attributed to venous congestion by the sequestered IRBC mass causing increased cerebral blood volume.…”

“…Both pediatric and adult BBB function has been studied clinically using fluorescein angiography of the retina, 13 cerebrospinal fluid (CSF) protein analysis, [17][18][19] and more recently magnetic resonance imaging (MRI) studies of the brain. 20,21 In children with cerebral malaria, there is clinical evidence of increased intracranial pressure leading to brainstem herniation. 22,23 In a recent antemortem MRI study of 168 children with CM in Malawi, brain swelling emerges as the most reliable predictor of severity.…”

Rupture and Release: A Role for Soluble Erythrocyte Content in the Pathology of Cerebral Malaria

“…In adults, brain swelling is less prominent but also an indicator of disease severity [2]. The recent serial magnetic resonance imaging (MRI) scanning of both pediatric and adult CM patients from India demonstrated for the first time that brain swelling mainly results from the loss of cerebral endothelial integrity.…”

Unexpected hosts: imaging parasitic diseases

“…Abdominal signs and symptoms of malaria are usually mild and nonspecific and include abdominal pain or hepatosplenomegaly [9, 10]. The neurological manifestations are nonspecific as well, but cerebral malaria can progress rapidly having a high mortality rate (15–40 %) [9, 11, 12]. The primary thoracic manifestation of malaria is adult respiratory distress syndrome (ARDS) [9, 13].…”