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Year : 2012  |  Volume : 58  |  Issue : 1  |  Page : 61-62

Falciparum malaria troubling neurosurgeons

Department of Surgery (Neurosurgery Unit), Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication25-Feb-2012

Correspondence Address:
N I Kamali
Department of Surgery (Neurosurgery Unit), Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.93256

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How to cite this article:
Kamali N I, Huda M F, Srivastava V K. Falciparum malaria troubling neurosurgeons. J Postgrad Med 2012;58:61-2

How to cite this URL:
Kamali N I, Huda M F, Srivastava V K. Falciparum malaria troubling neurosurgeons. J Postgrad Med [serial online] 2012 [cited 2023 Jun 4];58:61-2. Available from:

Malaria is a major health problem in tropical countries. Among its complications, cerebral malaria is the most devastating and can present as encephalopathy, hemiplegia, convulsions, delirium and death. Spontaneous intracranial hemorrhage complicating malaria is very rare. Subdural hematoma and subarachnoid bleed in malaria has been reported in the literature but spontaneous extradural bleed complicating falciparum malaria presenting as a neurosurgical emergency is being reported for the first time.

A 45-year-old male presented to our emergency department in altered sensorium. The patient was being treated at a private clinic for falciparum malaria from seven days. He got infected, probably at his home in his village where he used to sleep in the open. The nature of medication could not be ascertained as the patient had no treatment record.

He became disoriented and developed right-sided hemiparesis on the ninth day. Non-contrast computed tomography scan of the head revealed massive left-sided frontoparietal extradural hematoma with subfalcine and transtentorial herniation [Figure 1].
Figure 1: Non‑contrast‑enhanced computed tomography of head showing extra‑axial collection in the left frontoparietal region with midline shift and sub‑falcine herniation in axial view

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There was no history of trauma, seizures, intake of anticoagulant drugs by the patient. At the time of admission patient was febrile, had bradycardia, and blood pressure was 140/90. Glasgow Coma Scale (GCS) was 6. Blood examination revealed plasmodium falciparum, thrombocytopenia (platelet count 46000 per cc) and hypochromic anemia. Renal function, electrolytes and coagulation study was normal. The hematoma was completely evacuated through left-sided frontoparietal trephine craniotomy.

Postoperatively the patient was kept on antibiotics, antimalarials and antiepileptics. Since the patient had presented with severe malaria and was previously being treated at a private clinic for several days, it was presumed that the malaria may be multidrug-resistant. So the patient was treated with intravenous Artisunate as per standard protocol.

GCS started improving from the second postoperative day. By the third day the patient started localizing the painful stimulus, had spontaneous eye opening and spoke inappropriate words but unfortunately he aspirated following an episode of seizure late in the night, to which he finally succumbed.

Intracerebral hemorrhagic complications associated with malaria are exceedingly rare. Only three such cases have been reported in the literature so far. [1],[2],[3] This is the first case report of plasmodium falciparum malaria presenting as a neurosurgical emergency in the form of extradural hematoma. Infection with plasmodium falciparum leads to an increase in serum Tumor Necrosis Factor-α (TNF-α), whose concentrations correlate well with the severity of disease. [4] By up-regulating endothelial adhesion molecules, TNF-α may promote cerebral sequestration of platelets and red cells thus leading to hemorrhage. [5] Extradural hemorrhage in our patient may have been caused by the rupture of a small vessel plugged by red cells in combination with thrombocytopenia. So, if a patient of falciparum malaria suddenly develops focal neurological signs with clinical evidence of mass lesion, intracranial hemorrhagic complication can be a possible complication as seen in this case.

 :: References Top

1.Dwarakanath S, Suri A, Mahapatra AK. Spontaneous subdural empyema in falciparum malaria: A case study. J Vector Borne Dis 2004;41:80-2.  Back to cited text no. 1
2.Gall C, Spuler A, Fraunberger P. Subarachnoid hemorrhage in a patient with cerebral malaria. N Engl J Med 1999;341:6113.  Back to cited text no. 2
3.Murugavel K, Saravanapavananthan S, Anapalahan A, James RF. Subarachnoid haemorrhage in Plasmodium falciparum malaria. Postgrad Med J 1989;65:236-7.  Back to cited text no. 3
4.Grau GE, Taylor TE, Molyneux ME, Wirima JJ, Vassalli P, Hommel M, et al. Tumor necrosis factor and disease severity in children with falciparum malaria. N Engl J Med 1989;320:1586-91.  Back to cited text no. 4
5.Mannel DN, Grau GE. Role of platelet adhesion in homeostasis and immunopathology. Mol Pathol 1997;50:175-85.  Back to cited text no. 5


  [Figure 1]

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