title: Magnetic resonance imaging of the brain in adults with severe falciparum malaria.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 7LJ, UK. richardmaude@gmail.com.
authors.forename: Richard James
authors.initials: RJ
authors.lastname: Maude
authors.forename: Frederik
authors.initials: F
authors.lastname: Barkhof
authors.forename: Mahtab Uddin
authors.initials: MU
authors.lastname: Hassan
authors.forename: Aniruddha
authors.initials: A
authors.lastname: Ghose
authors.forename: Amir
authors.initials: A
authors.lastname: Hossain
authors.forename: M
authors.initials: M
authors.lastname: Abul Faiz
authors.forename: Ehsan
authors.initials: E
authors.lastname: Choudhury
authors.forename: Rehnuma
authors.initials: R
authors.lastname: Rashid
authors.forename: Abdullah
authors.initials: A
authors.lastname: Abu Sayeed
authors.forename: Prakaykaew
authors.initials: P
authors.lastname: Charunwatthana
authors.forename: Katherine
authors.initials: K
authors.lastname: Plewes
authors.forename: Hugh
authors.initials: H
authors.lastname: Kingston
authors.forename: Rapeephan Rattanawongnara
authors.initials: RR
authors.lastname: Maude
authors.forename: Kamolrat
authors.initials: K
authors.lastname: Silamut
authors.forename: Nicholas Philip John
authors.initials: NP
authors.lastname: Day
authors.forename: Nicholas John
authors.initials: NJ
authors.lastname: White
authors.forename: Arjen Mattheus
authors.initials: AM
authors.lastname: Dondorp
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001459:Bangladesh; D001921:Brain / Q000000981:diagnostic imaging* / Q000473:pathology*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D016779:Malaria, Cerebral / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009900:Optic Nerve / Q000000981:diagnostic imaging / Q000473:pathology; D011446:Prospective Studies; D011859:Radiography; D012160:Retina / Q000473:pathology; D014463:Ultrasonography; D055815:Young Adult