Treating Brain Swelling in Pediatric Cerebral Malaria

An important mechanism of death in children with cerebral malaria is diffuse cerebral swelling, cerebral herniation, compression of the brainstem respiratory center, and respiratory arrest. In those who survive their illness without specific interventions, reversal of diffuse cerebral swelling is rapid.

Mechanical ventilation may help to preserve life while diffuse brain swelling diminishes. Intravenous hypertonic saline may work as an osmotic diuretic, directly decreasing brain swelling.

Inclusion criteria

• Peripheral P. falciparum parasitemia of any density
• Blantyre Coma Score ≤2
• No evidence of meningitis on lumbar puncture
• Consciousness not regained after correction of hypoglycemia (if hypoglycemia is present)
• Male or female whose age on the day of screening is between 6 months and 12 years old
• Severely increased brain volume on magnetic resonance imaging
• Provision of consent by guardian
• Willingness to return for 1, 6, and 12 month post-randomization follow-up visits

Exclusion criteria

• Gross malnutrition as evidenced by peripheral edema, hair color changes, or severe wasting
• Advanced Human Immunodeficiency Virus (HIV) disease - defined as known HIV positive status and evidence of severe wasting
• Evidence of recent head trauma by history or physical examination
• Pneumonia as evidenced by oxygen saturation on room air of <85%
• Gastroenteritis and shock as evidenced by capillary refill >3 seconds or skin tenting