Cerebral malaria in resource-limited African regions: Diagnostic and therapeutic challenges

Abstract

• Cerebral malaria remains a leading cause of childhood morbidity and mortality in Sub-Saharan Africa despite advances in treatment and pathophysiological understanding. • Major challenges in cerebral malaria management include diagnostic limitations, treatment delays, inadequate supportive and critical care, and weak health system capacity. • Absence of reliable point-of-care diagnostics, limited fundoscopy skills, and lack of neuroimaging contribute significantly to misdiagnosis and poor outcomes. • Survivors of cerebral malaria face a high burden of long-term neurological sequelae, underscoring the need for structured follow-up and rehabilitation programs. • Priority interventions and research must focus on accessible diagnostics, timely treatment, simplified critical care, rehabilitation strategies, and comprehensive health system Cerebral malaria (CM) remains one of the most severe and life-threatening manifestations of Plasmodium falciparum infection, predominantly affecting children and pregnant women in Sub-Saharan Africa, where resource constraints compound diagnostic and therapeutic challenges. Despite significant advances in antimalarial therapy, CM continues to be associated with high mortality rates (15%–30%) and significant long-term neurological sequelae among survivors (10%–30%). Challenges in the diagnosis and management of CM in resource-limited African settings, include widespread misdiagnosis (up to 23% of clinically diagnosed CM cases may not meet strict diagnostic criteria), delayed presentation, inadequate supportive care infrastructure, and limited access to specialized neurological rehabilitation services. The lack of fundoscopic examination, neuroimaging capabilities, and reliable biomarkers in most African healthcare facilities compounds diagnostic challenges. Treatment delays due to poor referral systems, geographical barriers, and inadequate transportation significantly impact patient outcomes. In this review, the practical challenges of diagnosing and managing CM in resource-limited African healthcare settings, an area inadequately addressed in existing literature, is discussed while providing context-appropriate recommendations for each identified barrier. We address health systems constraints including workforce shortages, supply chain disruptions, and absent rehabilitation services for CM survivors. By synthesizing current evidence and highlighting critical gaps, this review aims to inform policy makers, clinicians, and researchers about priority areas for intervention to reduce CM-associated morbidity and mortality in African regions.