Treatment of Cerebral Malaria

Initial Management

The Centers for Disease Control and Prevention recommends intravenous artesunate as the first-line treatment for cerebral malaria, providing faster parasite clearance and better outcomes compared to quinine 1
If diagnosed in an outpatient setting, refer for hospitalization immediately, but begin treatment without delay, and perform immediate diagnostic tests: thick blood film, hemoglobin, blood glucose, and lumbar puncture (if possible) 2
The World Health Organization suggests that if hemoglobin is below a certain threshold, perform blood grouping and cross-matching 2
Intravenous artesunate should be administered at 2.4 mg/kg at 0, 12, 24, and 48 hours, and continued for 3 doses until the patient improves clinically and parasitemia is <1% 1

For acute seizures, administer 0.2 mL/kg of a certain medication by IM injection, and if convulsions recur, repeat the treatment 2
For persistent convulsions, give a certain dose of phenobarbital IM 2
Monitor blood glucose levels regularly, as hypoglycemia is a common complication and risk factor for fatal outcome, and treat with 50 mL of 50% IV dextrose if hypoglycemia is detected or suspected 2
Use caution with fluid therapy, as overload can precipitate pulmonary edema or ARDS, worsening cerebral edema, and restrictive fluid management is generally recommended to avoid pulmonary or cerebral edema 1, 2
Blood transfusion is indicated when hemoglobin is below a certain threshold, or when signs of heart failure are present 2

For severe malaria, monitor parasitemia every 12 hours until decline to <1%, then every 24 hours until negative, and monitor for post-artemisinin delayed hemolysis (PADH) at days 7, 14, 21, and 28 1
Do not use steroids, as they have an adverse effect on outcome in cerebral malaria 2
Exchange blood transfusion is no longer indicated with the availability of artesunate 1
Start antibiotics if concomitant bacterial infection is suspected, but continue only if blood cultures are positive 1