Peri-Rolandic and Occipital Sparing Cortical Edema: A Prevalent MRI Finding in Pediatric Patients with Cerebral Malaria

Lorenna Vidal, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Alireza Zandifar, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Jorge Du Kim, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Luis O. Tierradentro-García, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Siyu Heng, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Marcus Otavio de Campos Meneses, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Dylan Small, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Karen Chetcuti, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Nicole O'Brien, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Douglas Postels, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Terrie Taylor, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).
Manu S. Goyal, From the Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA (LV, AZ, JDUK, LOTG, MOSCM); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA (LV, LOTG); Department of Radiology, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AZ); Department of Radiology, University of Texas Southwestern, Dallas, TX, USA (JDUK); Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA (SH); Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia, PA, USA (DS, DP); Division of Radiology, Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi (KC); Department of Pediatrics, Division of Care Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA (NO); Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA (DP); Department of Osteopathic Medical Specialties College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA (TT); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA (MSG).

Document Type

Journal Article

Publication Date

7-30-2025

Journal

AJNR. American journal of neuroradiology

DOI

10.3174/ajnr.A8945

Abstract

BACKGROUND AND PURPOSE: Cerebral malaria is a leading cause of childhood mortality and neurological morbidity in sub-Saharan Africa and South Asia; and a strong association between diffuse brain swelling and mortality has been well established. Our goal was to characterize patterns of cortical edema on brain MRI in children with cerebral malaria and determine their association with patient outcomes. MATERIALS AND METHODS: We retrospectively reviewed admission brain MR images obtained from Malawian children with clinical cerebral malaria admitted at a single center from 2013-2019. Two neuroradiologists assessed the pattern of cortical edema on T1-, T2-, and diffusion-weighted images using a consensus approach. The overall degree of brain volume (brain volume score) and other brain imaging findings were also assessed, including focal signal changes in the basal ganglia, white matter, and posterior fossa. We evaluated the frequency and associations of these imaging findings with clinical outcomes at hospital discharge (deceased, alive with neurological sequelae, or alive without neurological sequelae). RESULTS: We included admission brain MRI scans from 190 children with clinical cerebral malaria. Cortical edema was identified in 163 MRIs. The predominant pattern of cortical edema was diffuse cortical involvement with relative sparing of the occipital and peri-Rolandic areas: 103 (63.2%) had this pattern, whereas 37 (22.7%) had sparing of the occipital cortex only and 23 (14.1%) had generalized cortical edema without focal sparing. The presence of occipital and peri-Rolandic sparing inversely correlated with brain volume score (β=-0.26, p<0.001) and outcomes (OR [95% CI]: 0.3 [0.1-0.6], p=0.002). CONCLUSIONS: Pediatric cerebral malaria is associated with a typical pattern of cortical edema that relatively spares the occipital and peri-Rolandic areas, which become progressively involved with more severe disease. ABBREVIATIONS: CM = Cerebral Malaria; BVS = Brain Volume Score; DWI = Diffusion-Weighted Imaging; PRES = Posterior Reversible Encephalopathy Syndrome.

Department

Neurology

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