Diagnosis and management of the neurological complications of falciparum malaria

Malaria is a serious public health problem in the developing world, and is also being seen increasingly in Western countries as a result of travel and immigration. Malaria is associated with a number of neurological complications, including agitation, psychosis, seizures, impaired consciousness and coma. In this article, Mishra and Newton describe these complications, discuss the underlying pathogenesis, and outline current and future management strategies. Malaria is a major public health problem in the developing world owing to its high rates of morbidity and mortality. Of all the malarial parasites that infect humans, Plasmodium falciparum is most commonly associated with neurological complications, which manifest as agitation, psychosis, seizures, impaired consciousness and coma (cerebral malaria). Cerebral malaria is the most severe neurological complication; the condition is associated with mortality of 15–20%, and a substantial proportion of individuals with this condition develop neurocognitive sequelae. In this Review, we describe the various neurological complications encountered in malaria, discuss the underlying pathogenesis, and outline current management strategies for these complications. Furthermore, we discuss the role of adjunctive therapies in improving outcome. Key Points Neurological complications are common in falciparum malaria; cerebral malaria is the most severe and is associated with almost all neurocognitive sequelae and deaths from neurological complications The pathogenesis of the neurological complications is multifactorial, with sequestration of infected erythrocytes in the brain the probable cause of most neurological complications Subtle deficits such as cognitive impairments are often undetected, and few data are available on the incidence of and therapeutic options to prevent brain damage The mainstay of malaria therapy is parenteral quinidine, quinine or artesunate; artesunate is the treatment of choice where available Adjunctive therapies might help to improve outcomes, but as yet none has unequivocally been shown to be beneficial