Dear Editor,
We were interested to read Esht’s article on a review and meta-analysis of the effect of virtual cognitive training (VCT) on cognitive deficits induced by cerebral malaria in pediatric patients from six randomized controlled trials.[1] Cognitive functions such as memory, executive functions, and attention were found to improve with 16–24 sessions of VCT, each lasting 45–60 min. Tailored programs based on different subcategories of cognitive performance are needed to improve neuropsychological performance and behavior after cerebral malaria.[1] The study is noteworthy, but several points should be discussed.
The first point is that the success of VCT after cerebral malaria in children may be highly dependent on the degree of structural and functional damage caused by the brain infection. Therefore, it would be desirable that the degree of cerebral destruction according to cerebral imaging is also included in the study. The more severely the brain is damaged, the less likely it is that VCT will be successful or not. Regarding the extent of cerebral damage, the analysis should include how many of the included patients had meningitis, encephalitis, vasculitis, or a combination of these three conditions. Destruction of cortical structures may have a different impact on the outcome of VCT than subcortical lesions or even infra-tentorial impairments due to infection.
The second point is that the effect of VCT training may also depend on the presence of long-term sequelae of cerebral malaria. One of the long-term complications of cerebral malaria is structural epilepsy.[2] As the quality of seizure control may contribute to the effect of VCT, the presence of seizures and seizure control by anti-seizure medication should be included in the analysis. How many of the patients analyzed had epilepsy, and did those with poor seizure control derive less benefit from VCT than those in whom cerebral malaria was not complicated by seizures?
The third issue is that the age factor was not included in the analysis.[1] Since the ability to perform virtual tasks is highly dependent on age, we should know whether the therapeutic effect was age dependent. Did older children benefit more than younger ones and were the applied programs specifically designed for certain age groups?
The fourth point is that the time between the onset of cognitive impairment and the start of VCT was not included in the analysis.[1] The longer the latency period between the onset of CM and the start of VCT, the less likely it is that a patient will benefit from the intervention.
To summarize, this interesting study has limitations that affect the results and their interpretation. Addressing these limitations could strengthen the conclusions and support the message of the study. Before recommending VCT for rehabilitation of cerebral malaria in pediatric patients, all factors affecting cognition need to be considered.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Esht V, Sharma A, Alshehri MM, Bautista MJ, Uddin S, Shaphe MA, et al. Neuropsychological and behavioral benefits of virtual cognitive rehabilitation training among pediatric population surviving malaria: A systematic review and meta-analysis. Int J Crit Illn Inj Sci. 2025;15:35–43. doi: 10.4103/ijciis.ijciis_74_24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Albrecht-Schgoer K, Lackner P, Schmutzhard E, Baier G. Cerebral malaria: Current clinical and immunological aspects. Front. Immunol. 2022;13:863568. doi: 10.3389/fimmu.2022.863568. [DOI] [PMC free article] [PubMed] [Google Scholar]