Intracranial pressure (ICP) was monitored and cerebral perfusion pressure (CPP) calculated in 23 African children suffering from cerebral malaria and treated at the Kenya Medical Research Institute, Clinical Research Center, Kilifi, Kenya. Of 4 children with severe intracranial hypertension (ICP >40 mm Hg, CPP <40 mm HG), 2 died with transtentorial herniation and cardiorespiratory arrest, 2 had severe neurological sequelae. The remainder with mild (<20 mm Hg) or intermediate intracranial hypertension (<40 mm Hg) survived without severe sequelae. Mannitol was of value only in children with intermediate intracranial hypertension and ICP <40 mm Hg. Corticosteroids are detrimental in adults with cerebral malaria and have not been used in children. Osmotherapy is not recommended by the WHO. [1]

COMMENT. The authors cite possible causes of intracranial hypertension in cerebral malaria, including increase in cerebral blood volume (CBV), cerebral edema, and hydrocephalus. Increased CBV seemed most likely from CT and MRI studies. Clinical signs of ICP, pupil dilatation and decerebrate posturing, are unreliable in estimating severity of intracranial hypertension, and the benefits of ICP monitoring need controlled evaluation. My colleague, Dr Charles Swisher, who treated malaria in the Service in Vietnam, referred to the interference with the vascular supply to the central nervous system in cerebral malaria, due to sludging and thrombosis caused by intravascular parasites, and consequent ischemia and anoxemia. Hyperpyrexia and convulsions are common symptoms. [2]