Magnetic resonance imaging in cerebral malaria: a report of four cases

Abstract

Objectives: This is a retrospective institutional review of clinical data and radiological findings of cerebral malaria patients presenting to a tertiary centre in India, which is an known to be endemic for malarial disease.

Methods: The present series describes MRI in four cases all of which revealed bithalamic infarctions with or without haemorrhages in patients with cerebral malaria, and this review examines a subset of patients with this condition. In addition, acute haemorrhagic infarctions were also seen the in brain stem, cerebellum, cerebral white matter and insular cortex in two of the four patients.

Results: In this series, the patient with cerebellum and brain stem involvement died. The remaining three survived with antimalarial and supportive treatment. No neurological symptoms were noted on clinical follow-up. MRI follow-up was obtained in only one of the three patients (3 months post-treatment) and showed resolution of thalamic infarctions.

Conclusion: These imaging features may help in the early diagnosis of cerebral malaria so that early treatment can begin and improve the clinical outcome.

Figures

Figure 1

48-year-old male found comatose on admission with Glasgow coma scale (GCS) 4/15. Axial T2 weighted images showing multiple foci of hyperintensities in (a) bilateral thalami (black arrows); (b) brain stem (arrowhead); and (c) cerebellar hemispheres (white arrows). (d) Axial T1 weighted image showing corresponding hypointensities in the bilateral thalami (white arrows). Axial gradient-echo images show blooming artefacts in (e) bilateral thalami (black arrows) and (f) brain stem (arrowhead) compatible with petechial haemorrhages. Axial diffusion weighted images showing restricted diffusion in (g) bilateral thalami (black arrows), (h) brain stem (arrowheads) and cerebellar hemispheres (white arrows).

Figure 2

A 32-year-old female presented with a history of fever, chills and rigors for the past 10 days. Axial T2 weighted images show multiple foci of hyperintensities in the (a) right corona radiata (black arrow), (b) posterior limb of bilateral internal capsule/thalami (arrowheads) and (c) left temporal lobe/hippocampus extending into the left insular cortex (white arrows). Axial gradient-echo images showing old haemorrhages in (d) right corona radiata (black arrow) and (e) left temporal lobe/hippocampus (white arrow). Axial diffusion-weighted images showing restricted diffusion in right corona radiata (arrows).

Figure 3

A 25-year-old male presented with history of fever and sudden blurring of vision followed by dizziness for 5–6 days. Axial diffusion-weighted images showing restricted diffusion in bilateral thalami (arrows).

Figure 4

A 55-year-old male presented with sudden onset slurring of speech, diplopia and droop of left eyelid. (a) Axial T2 weighted images showing multiple foci of hyperintensities in bilateral thalami (black arrows) and (b) periaqueductal grey matter (white arrows). (c) Axial gradient-echo image showing petechial haemorrhages in the left thalamus (white arrow). (d) Axial diffusion weighted images showing restricted diffusion in the thalami (black arrows) and periaqueductal grey matter extending into the brain stem (white arrow).