A retrospective chart review for the 1993 calendar year identified 187 children with cerebral malaria admitted to a large teaching hospital in central Ghana, West Africa. The most common clinical presentation was fever, sensorial depression and convulsions in young children experiencing their first episode of malaria. One-half had splenomegaly. Additional features, seen in decreasing frequency, were hepatomegaly, vomiting, abdominal pain and headache. Long term sequelae were identified in 9% and mortality in 6%. Risk factors for central nervous system disease were negative history for previous malaria (P < 0.005) and a high percentage of parasitemia (P < 0.001). Death or long term sequelae were associated with multiple seizures and prolonged sensorial depression. The incidence of malaria is currently increasing in Western Africa and young children are more likely than older children to develop severe disease.