BACKGROUND: No comprehensive data on the clinical features and the prognosis of cerebral malaria in the South Pacific are available at present. We conducted a prospective study in children with cerebral malaria to assess the case fatality rate (CFR) in the region and to identify potential risk factors for death. METHODS: We recruited 134 children admitted to the Madang General Hospital between April 1991 and October 1993 with a strictly defined diagnosis of cerebral malaria. Besides clinical examination, we collected a blood sample for parasitological haematological and biochemical assessment. RESULTS: The CFR was 11.9% and the prevalence of residual neurological sequelae at discharge was 1.5%. The proportion of children presenting with deep coma (12%) or hypoglycaemia (17%) was lower in our study than in African ones, where severe complications are more frequent. Also mortality associated with hypoglycaemia on admission was lower. Clinical or laboratory conditions significantly associated with death were deep coma, malarial anaemia and hyperleucocytosis. CONCLUSIONS: All conditions associated with deep coma, such as shock, hypoglycaemia and acidosis, should be corrected. Also prompt administration of blood transfusions to patients with anaemia is likely to reduce the occurrence of death in Papua New Guinean children with cerebral malaria.