What is the recommended treatment for cerebral malaria?

Cerebral Malaria Treatment

First-Line Treatment: Intravenous Artesunate

Intravenous artesunate is the definitive first-line treatment for cerebral malaria, administered at 2.4 mg/kg IV at 0,12,24, and 48 hours, providing superior outcomes and faster parasite clearance compared to quinine. 1, 2

• Continue artesunate for at least 3 doses until clinical improvement occurs and parasitemia drops below 1% 2
• Once the patient can tolerate oral medications and parasitemia is <1%, switch to a complete oral artemisinin-based combination therapy course 3
• Artesunate reduces mortality more effectively than quinine, with studies showing mortality rates of 8.3% versus 34.3% with quinine-based regimens 4

Alternative Treatment: Intravenous Quinine

If artesunate is unavailable, use intravenous quinine as second-line therapy 3, 1:

• Loading dose: 20 mg salt/kg over 4 hours 3, 1
• Maintenance: 10 mg/kg every 8 hours, starting 8 hours after initiation of the loading dose 3
• Critical caveat: Omit the loading dose if the patient received quinine or mefloquine within the previous 24 hours 1, 5
• Switch to oral therapy after completing at least 48 hours of IV treatment when feasible 3
• Monitor for QT prolongation and hypoglycemia due to insulin release 3

Seizure Management

Use a stepwise anticonvulsant protocol for active seizures, but never use prophylactic anticonvulsants 1:

• First-line: Lorazepam 0.1 mg/kg IV/IO; repeat once if seizure persists 1
• Alternative: Paraldehyde 0.2 mL/kg IM; repeat if convulsions recur 3, 2
• Refractory seizures: Phenobarbital 10 mg/kg IM 3, 2, 5
• Critical warning: Prophylactic phenobarbital increases mortality in cerebral malaria, particularly when combined with multiple doses of benzodiazepines due to respiratory depression 1

Critical Supportive Care

Hypoglycemia Management

• Monitor blood glucose regularly—hypoglycemia is a common and potentially fatal complication 1, 2, 5
• Treat immediately with 50 mL of 50% IV dextrose if detected or suspected 1, 5

Fluid Management

• Use restrictive fluid therapy to avoid pulmonary or cerebral edema 1, 2, 5
• Fluid overload can precipitate ARDS and worsen cerebral edema 1, 5
• Preferred IV fluid: 5% dextrose with 1/2 normal saline to prevent hypoglycemia while minimizing salt leakage 5

Raised Intracranial Pressure

• Treat as a medical emergency with rapid intubation and mechanical ventilation 1
• Maintain PaCO2 in the normal range 1
• Consider mannitol 0.5 mg/kg IV over 5-10 minutes 1
• Never use steroids—they worsen outcomes in cerebral malaria 1, 2, 5

Essential Monitoring

Parasitemia Surveillance

• Check every 12 hours until decline to <1%, then every 24 hours until negative 1, 2, 5
• Parasitemia may increase in the first 24 hours with quinine—this does not indicate treatment failure 1

Post-Artesunate Delayed Hemolysis (PADH)

• Monitor at days 7,14,21, and 28 post-treatment 1, 2, 5
• Check hemoglobin, haptoglobin, and lactate dehydrogenase 1

Blood Transfusion Indications

• Hemoglobin <4 g/dL, or <6 g/dL with signs of heart failure 1, 2, 5

Additional Diagnostic and Treatment Considerations

• Perform lumbar puncture to rule out bacterial meningitis or other causes of encephalitis 1, 2, 5
• Start antibiotics only if bacterial co-infection is suspected; continue only if blood cultures are positive 1, 2, 5
• Exchange transfusion is not indicated with artesunate availability 1, 2, 5
• Begin treatment immediately in outpatient settings before transfer to hospital—do not delay 2, 5