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Infectious Disease and Neurocognition
neurocognitive impairment and found that CSF TNF- α levels were associated with
neurologic decits at hospital discharge as well as with longer coma duration during
acute illness and neuropsychological decits in school- age survivors at 6- month
follow- up post discharge (Shabani et al., 2017). In a follow- up study, this group
conrmed that elevated CSF tau protein concentrations on admission were associated with long- term neurologic and cognitive impairment in Ugandan children
with CM (Datta et al., 2020). Other biomarkers contributing to the pathogenesis
of CM by promoting endothelial activation and parasite sequestration, such as von
Willebrand factor (vWF) and angiopoietin- 2, have also been related to long- terms
neurocognitive sequelae in Ugandan children surviving CM by this group (Ouma
et al., 2020, 2021; Park et al., 2008, 2012).
Boivin and colleagues demonstrated that the level of vWF during acute CM
illness was predictive of the degree of improvement from CCRT in terms of attention and maze learning performance (unpublished data; see Figure 13.3).
Holding and Boivin in their review of the neuropsychological eects of CM in
Ugandan school- age survivors (Boivin et al., 2007) also documented that vWF,
CSF Regulated on Activation, Normal T- cell Expressed and Secreted (RANTES),
and granulocytes colonizing factor levels during acute illness were predictive
of long- terms decits in vigilance attention and working memory (Holding &
Boivin, 2013). John and colleagues had documented earlier that lower levels of
CSF RANTES during acute illness was predictive of mortality in CM children
(John et al., 2006). Based on these ndings, Boivin and colleagues proposed that
these three biomarkers— TNF- α, vWF, and RANTES— would be predictive of
the extent to which SMA and CM survivors would benet from a neurocognitive
rehabilitation intervention as presented in their CCRT RCT study (Figure 1 in
Boivin et al., 2019a).
In their study, TNF- α, vWF, and RANTES were assayed from plasma and CSF
of Ugandan children during the acute illness phase of SMA or CM (Boivin et al.,
2019b). Two years aer acute malaria illness, 150 surviving children 6– 12 years
old entered a three- arm RCT (KABC), the TOVA and the CBCL were administered before and aer 24 CCRT sessions over a 3- month period and at 1- year
follow- up. Using linear mixed- eects models, Boivin and colleagues determined
that severe malaria survivors with lower levels of vWF, lower CSF levels of TNF- α,
and higher levels of plasma and CSF RANTES had better KABC cognitive performance aer both titrating and non- titrating CCRT, compared to no CCRT.
For the CBCL (total psychiatric symptoms), high plasma RANTES was associated with no benet from either the titrating or non- titrating CCRT, while high
plasma TNF- α was predictive of the benet for both interventions. is was the
rst evidence in the published literature that severe malaria immunopathogenic
biomarkers may be related to poorer long- term brain and behavior function as
evidenced by diminished benet from a CCRT intervention administered in an
RCT (Boivin et al., 2019b).

Cerebral Malaria 199
Using machine learning algorithms to model
neurodevelopmental outcomes in cerebral
malaria survivors
Using our well- characterized cohort of Ugandan CM survivors who were then enrolled into our later CCRT follow- up studies, Leonenko et al. (2023) explored the use
of machine learning algorithms to model their neurodevelopmental outcomes using a
new strictly stationary time series model with marginal generalized Gaussian distributions. e EEG data previously prepared for their prior automated stochastic analyses
(Veretennikova et al., 2018) also were used in these exploratory analyses. eir generalized Gaussian time series modeling for EEG increments, however, was expanded
to include clinical biomarkers during acute illness (Blantyre coma score, hemoglobin
level, white blood cell count), CSF proinammatory biomarkers, and other immunepathogenic regulators (interleukin (IL)- 10, IL- 1α, IL- 1α receptor levels (plasma),
IL- 6, and vWF). eir analyses also included quality of the Home Environment
Measurement Evaluation (HOME) assessments done at the child/ caregiver’s home.
is measure was used to evaluate the child’s developmental milieu to control for the
quality of the home environment as developmental and neuropsychological outcomes
at 6- and 12- month follow- up aer hospital discharge. We could then also better gauge
the extent to which CCRT neuropsychological benets were modied by CM acute
illness severity based on acute illness biomarker levels in any subsequent CCRT intervention studies. Veretennikova and colleagues concluded that the addition of stochastic EEG modeling improved the prediction of children’s brain function 6 months
following coma and that it can be used prognostically during the acute phase of illness
for longer- term neurocognitive outcomes for CM survivors (Leonenko et al., 2023).
Again, this can of great benet in resource- constrained settings where a thorough
EEG and immunopathogenic interpretive workup and evaluation may not always be
readily available on site but for which the EEG study and biomarker data can be accessed for machine- learning analyses. Dynamic neurocognitive learning outcomes,
such as those provided by CCRT, along with a comprehensive prognostic machinelearning analysis of clinical and immunopathogenic biomarkers can be applied in
the evaluation of outcomes of new generations of adjuvant therapies being considered to enhance the ecacy of CM and SMA treatment during the acute phase.
One such very promising treatment is considered in the nal portion of this review.
Protective role of neuregulin- 1 against cerebral
malaria- induced neuronal injury and behavioral sequelae
e remaining sections of this chapter review will be dedicated to an overview of
the aims and potential benets of parental artemisinins in providing CM and SMA

Infectious Disease and Neurocognition
survivors with the opportunity for a life free of long- terms neurodevelopmental and
behavioral decits. Furthermore, we hope that behavioral interventions such as CCRT
can be used as sensitive dynamic and culture- fair neurodevelopmental measures of
brain and behavioral integrity in the aermath of more eective combination treatment during the acute phases of SMA and CM as well as for other infectious disease
of the brain for which children in tropical regions can be especially at risk (Bangirana
et al., 2013a; Boivin & Giordani, 2009, 2013). Brain- powered game apps for administering CCRT on tablet devices are presently being evaluated for this purpose with
Ugandan and Malawian school- age children aected by HIV (Boivin, 2019).
ere is still a need for eective combination treatments that can further diminish
the long- term risk of neurological, neurocognitive, and behavioral sequelae in CM
survivors. Professor Jonathan Stiles is presently leading a translational science initiative that is evaluating the protective role of neurogelin- 1 as an adjuvant therapy
for CM that could be used during the acute phase to further improve long- term
neurocognitive and behavioral outcomes (Stiles, 2021). Presently no other proven
treatments exist for the pathogenic pathways that Professor Stiles and his team have
identied as being critical to the mortality and morbidity caused by CM.
Results from previous studies show that heme and Plasmodium falciparum antigen histidine- rich protein 2 (HRP2) by- products of parasitized red blood cell lysis
during severe P. falciparum infection are major causes of brain inammation, blood–
brain barrier (BBB) dysfunction, and brain tissue injury (Harbuzariu et al., 2022).
Studies conducted in Ghanaian children dying of CM, severe malarial anemia, and
non- malarial causes identied several biomarkers that could potentially predict CM
severity and mortality (Armah et al., 2005a, 2005b). e study found CSF and serum
biomarkers that were signicantly elevated in the CM mortality group when compared to severe malarial anemia and non- malarial deaths. eir ndings revealed
additional biomarkers beyond those reported in Uganda that could be used to predict severity and mortality of CM. ey included IL- 1 receptor antagonist, IL- 8,
interferon gamma- induced protein 10 (IP- 10), platelet- derived growth factor BB
(PDGF- BB), macrophage inammatory protein- 1 beta (MIP- 1β), Fas- ligand (FasL), soluble tumor necrosis factor receptor 1 (sTNF- R1), and soluble tumor necrosis
factor receptor 2 (sTNF- R2). Additionally, the CSF IP- 10/ PDGF- BB median ratio
was statistically signicantly higher in the CM group compared to severe malarial
anemia and non- malarial groups.
It is important to note that the pathogenesis of CM and other forms of severe malaria is multifactorial and appears to involve cytokine and chemokine homeostasis,
inammation, oxidative stress, lipid peroxidation and apoptosis, as well as neuronal
and vascular injury/ repair. Further research is needed to identify more prognostic
markers and development of algorithms that can predict CM severity and enable the
development of better interventions.
Further work in this area has concluded that heme- mediated apoptosis in human
brain vascular endothelial cells (HBVEC) was mediated through tumor protein
p73 and that it induces apoptosis of BeWo cells, a trophoblast- derived cell line,

Cerebral Malaria 201
by activating the STAT3/ caspase 3/ PARP signaling pathway and reducing trophoblast cell fusion. Interestingly, neuregulin- 1, an 8 kDa anti- inammatory peptide currently undergoing clinical trials against traumatic brain injury, attenuated
heme- induced injury of endothelial and neuronal cells in vitro and in vivo (M. Liu
et al., 2018). In their mouse model of CM infection, they showed that adjunctive
infusion of neuroregulin- 1 during administration of conventional anti- malarial
therapy signicantly reduced brain injury and BBB permeability and increased survival. Further, neuroregulin- 1 treatment stimulated phosphorylation of its receptor
ErbB4, activated AKT, and inactivated STAT3 in hCMEC/ D3 brain microvascular
endothelial cells (Harbuzariu et al., 2022).
In a mouse model, CM resistant (BALB/ c) mice constitutively expressed higher
levels of neuroregulin- 1 in brain tissue than CM susceptible (C57BL/ 6) mice during
Plasmodium berghei ANKA (PbA) infection, indicating a key role for neuroregulin1 in susceptibility to CM- associated mortality (M. Liu et al., 2018). In human CM
studies at their two eld sites in India and Ghana, the authors observed signicantly lower serum neuroregulin- 1 in fatal disease than in mild malaria and healthy
controls, indicating a correlation of serum neuroregulin- 1 levels with severity of
human CM. is team proceeded to employ a human brain organoid model to test
the hypothesis that exogenous neuroregulin- 1 treatment could abrogate heme and
HRP2- induced elevation of key markers of brain inammation (CXCL10, TNFα, IL- 8, IL- 10, Fas- L, and others), neuronal injury (neurolaments), as well as a
heme- induced scavenger markers (heme oxygenase- 1 (HO- 1), haptoglobin, and
hemopexin). Utilizing urine- derived cells reprogrammed to induced pluripotent
stem cells, they have developed a brain chip model of the neurovascular unit that will
be used in conjunction with human and murine CM studies to determine the eects
of heme and HRP2 on BBB function in vitro (Harbuzariu et al., 2022).
Further recent studies indicate that enhancement of the programmed death- 1 (PD1/ PD- L1) signaling pathway using a PDL1– IgGFc fusion protein led to amelioration
of BBB dysfunction and increased CM survival. Antibody- mediated blockade of PD1/ PD- L in experimental CM- resistant BALB/ c mice resulted in increased T- cell activation, enhanced IFN- gamma production, increased recruitment of both pRBC and
CD8+ T cells in the brain, and augmented experimental CM in experimental CM
susceptible (C57BL/ 6) mice (Wang et al., 2024). us, the availability of the novel murine and three- dimensional tissue culture models provides new opportunities to test
new interventions (repurposed drugs, or small molecules) in a noninvasive manner.
Potential for impact in the adjuvant treatment
of cerebral malaria to improve survival and
reduce morbidity
Understanding the role of neuoregulin- 1 in the pathogenesis of CM will enable determining whether neuroregulin- 1 will improve survival in children with CM. Most

Infectious Disease and Neurocognition
adjunctive treatments developed to date against CM have not reduced fatal outcomes in part because treatments have focused on clearance of circulating parasites
but have neglected the involvement of damaging parasite and host factors appearing
early in infection or remaining aer treatment.
Conclusion
CM is a common childhood encephalopathy in areas where malaria is endemic including sub- Saharan Africa. A variety of cognitive and neurodevelopmental adverse
eects are associated with CM. Clinical and immunopathogenic biomarkers during
acute malaria can aect the overall course of the cognitive and neurodevelopmental
decits associated with CM. Further, a variety of interventions might improve
the cognitive and neurodevelopmental decits associated with CM, including
neuroregulin- 1, although proximal neuropathological mechanisms of CM must
be disentangled from the more distal eects of long- term neurodevelopmental and
neurocognitive outcomes that implicate a variety of pathways for at- risk children.
e development of novel and innovative treatments to prevent and remediate
neurocognitive sequelae for CM survivors and other brain infections prevalent in
regions where malaria is endemic are desperately needed.
Acknowledgments
Funding support for original ndings presented in this review was provided by R01
HD064416 (principal investigators: Boivin and Nakasujja) and R01 NS055349 (principal investigator: John). Funding support for the evaluation of the protective role
of neurogolin- 1 adjuvant therapy research program is provided by 2R01 NS091616
(principal investigator: Stiles). e funders had no role in the conceptualization and
content of this chapter review.
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