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Reynolds AS. Neuroinfectious Emergencies. Continuum (Minneap Minn) 2024; 30:757-780. [PMID: 38830070 DOI: 10.1212/con.0000000000001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article describes nervous system infections and complications that lead to neurologic emergencies. LATEST DEVELOPMENTS New research on the use of dexamethasone in viral and fungal infections is reviewed. The use of advanced MRI techniques to evaluate nervous system infections is discussed. ESSENTIAL POINTS Neurologic infections become emergencies when they lead to a rapid decline in a patient's function. Emergent complications may result from neurologic infections that, if not identified promptly, can lead to permanent deficits or death. These complications include cerebral edema and herniation, spinal cord compression, hydrocephalus, vasculopathy resulting in ischemic stroke, venous thrombosis, intracerebral hemorrhage, status epilepticus, and neuromuscular respiratory weakness.
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Bajons D, Fröhlich R, Grandits W, Krstic M, Rauschka H, Katzenschlager R. Lyme neuroborreliosis: Progressive cerebral vasculitis responsive to cyclophosphamide. A case report and review of the literature. J Stroke Cerebrovasc Dis 2023; 32:107220. [PMID: 37336186 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/12/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES Less than 1 % of patients with Lyme Neuroborreliosis (LNB) present with a cerebrovascular event. Ischaemic strokes occur more commonly than parenchymal or subarachnoid haemorrhages. If cerebral vasculitis due to LNB is suspected, antibiotic treatment should be started immediately, which will normally lead to remission. Very rarely progression and recurrent strokes are observed despite sufficient antibiotic therapy, even if steroids are added. Currently there are no guidelines on the adequate treatment of cerebral vasculitis due to LNB which is not responsive to antibiotics and steroids, but in very few reported cases cyclophosphamide led to disease stabilisation. We reviewed the literature regarding cyclophosphamide treatment in these patients and want to share our experience of cyclophosphamide therapy in progressive cerebral vasculitis due to LNB. RESULTS We report a 71-year-old female patient with cerebral vasculitis and multiple strokes as a complication of LNB. Progression could only be halted by additional immunosuppressive treatment using cyclophosphamide. However, at that point the patient had already suffered severe ischaemic brain damage. Similarly, in existing case reports cyclophosphamide had been administered only at a time when patients already showed serious neurological deficits. CONCLUSION Cerebral vasculitis in patients with LNB is very rare and normally responds to antibiotic treatment. A minority of patients show disease progression despite antibiotics and steroids. Our case report strengthens the recommendation that in those patients - even if signs of progressive vasculitis are only detectable on imaging and not clinically - cyclophosphamide should be considered without delay to prevent further cerebrovascular events.
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Affiliation(s)
- Désirée Bajons
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria.
| | - Roman Fröhlich
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria
| | - Waltraud Grandits
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria
| | - Miroslav Krstic
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria
| | - Helmut Rauschka
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria; Karl Landsteiner-Institute for Neuroimmunological and Neurodegenerative Conditions, Vienna, Austria
| | - Regina Katzenschlager
- Department of Neurology, (former name of the institution: social medical center east) Klinik Donaustadt, Vienna, Austria; Karl Landsteiner-Institute for Neuroimmunological and Neurodegenerative Conditions, Vienna, Austria
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3
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Philipps J, Erdlenbruch B, Kuschnerow M, Jagoda S, Salihaj B, Glahn J, Schellinger PD. Hyperacute treatment of childhood stroke in Lyme neuroborreliosis: report of two cases and systematic review of the literature. Ther Adv Neurol Disord 2022; 15:17562864221102842. [PMID: 36061261 PMCID: PMC9437258 DOI: 10.1177/17562864221102842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
The safety and efficacy of hyperacute reperfusion therapies in childhood stroke
due to focal cerebral arteriopathy (FCA) with an infectious and inflammatory
component is unknown. Lyme neuroborreliosis (LNB) is reported as a rare cause of
childhood stroke. Intravenous thrombolysis (IVT) and endovascular therapy (EVT)
have not been reported in LNB-associated stroke in children. We report two
children with acute stroke associated with LNB who underwent hyperacute stroke
treatment. A systematic review of the literature was performed to identify case
reports of LNB-associated childhood stroke over the last 20 years. Patient 1
received IVT within 73 min after onset of acute hemiparesis and dysarthria;
medulla oblongata infarctions were diagnosed on magnetic resonance imaging
(MRI). Patient 2 received successful EVT 6.5 hr after onset of progressive
tetraparesis, coma, and decerebrate posturing caused by basilar artery occlusion
with bilateral pontomesencephalic infarctions. Both patients exhibited a
lymphocytic cerebrospinal fluid (CSF) pleocytosis and elevated antibody index
(AI) to Borrelia burgdorferi. Antibiotic treatment, steroids,
and platelet inhibitors including tirofiban infusion in patient 2 were
administered. No side effects were observed. On follow-up, patient 1 showed good
recovery and patient 2 was asymptomatic. In the literature, 12 cases of
LNB-associated childhood stroke were reported. LNB-associated infectious and
inflammatory FCA is not a medical contraindication for reperfusion therapies in
acute childhood stroke. Steroids are discussed controversially in inflammatory
FCA due to LNB. Intensified antiplatelet regimes may be considered; secondary
prophylaxis with acetyl-salicylic acid (ASA) is recommended because of a high
risk of early stroke recurrence.
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Affiliation(s)
- Joerg Philipps
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Hans-Nolte-Str. 1, D-32429 Minden, Germany
| | - Bernhard Erdlenbruch
- Department of Pediatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Michael Kuschnerow
- Department of Diagnostic and Interventional Radiology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Sunil Jagoda
- Department of Anesthesiology and Intensive Care, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Blerta Salihaj
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Joerg Glahn
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Peter Dieter Schellinger
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
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Erhart DK, Bracknies V, Lutz-Schuhbauer S, Wigand S, Tumani H. The special role of CXCL13 in Lyme neuroborreliosis: a case report. Neurol Res Pract 2022; 4:3. [PMID: 35034645 PMCID: PMC8762870 DOI: 10.1186/s42466-022-00167-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
The diagnosis of chronic lyme neuroborreliosis can be a challenge even for experienced neurologists. The clinical picture may be multifaceted, including polyradiculitis to cranial nerve palsies, meningitis, encephalomyelitis, encephalopathy and peripheral neuropathy. We report on a patient presenting with basal leptomeningoencephalitis associated with vasculopathy where the chemokine CXCL13 in cerebrospinal fluid played an important diagnostic role.
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Affiliation(s)
- Deborah K Erhart
- Specialty Hospital of Neurology Dietenbronn, Dietenbronn 7, 88466, Schwendi, Germany. .,Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Vera Bracknies
- Specialty Hospital of Neurology Dietenbronn, Dietenbronn 7, 88466, Schwendi, Germany
| | | | - Sonja Wigand
- Specialty Hospital of Neurology Dietenbronn, Dietenbronn 7, 88466, Schwendi, Germany
| | - Hayrettin Tumani
- Specialty Hospital of Neurology Dietenbronn, Dietenbronn 7, 88466, Schwendi, Germany.,Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
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5
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Skripchenko E, Ivanova G, Skripchenko N, Egorova E. Modern concepts on the pathogenesis of neuroborreliosis. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:27-35. [DOI: 10.17116/jnevro202212207127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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6
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Borreliosi di Lyme e neuroborreliosi. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45319-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
PURPOSE OF REVIEW This article reviews the symptomatology, diagnosis, and treatment of neuroborreliosis. RECENT FINDINGS The most recent guidelines for the diagnosis and treatment of Lyme disease were published in 2020 by the Infectious Diseases Society of America, the American Academy of Neurology, and the American College of Rheumatology. SUMMARY The most common neurologic complications of Lyme disease are cranial neuritis (most often a unilateral or bilateral facial nerve palsy), meningitis, and radiculoneuritis/mononeuropathy multiplex. Testing for Lyme disease begins with an enzyme-linked immunosorbent assay (ELISA). If the ELISA is positive or borderline, Western blots should be performed for both IgM and IgG antibodies. As a general rule, in infectious diseases, an IgM antibody response is followed by an IgG antibody response. A central nervous system infection has either a CSF pleocytosis or pathogen-specific intrathecal antibody production. Lyme meningitis, cranial neuropathy, radiculoneuropathy, or other peripheral nervous system manifestations are treated with oral doxycycline or IV ceftriaxone, cefotaxime, or penicillin G. No additional antibiotic therapy is indicated for patients with posttreatment Lyme disease syndrome or patients with concern for chronic Lyme disease with no evidence of previous or current Lyme infection.
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Lyme neuroborreliosis-associated cerebrovascular events in the Finnish endemic area. J Neurol Sci 2021; 427:117544. [PMID: 34153843 DOI: 10.1016/j.jns.2021.117544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/31/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Neuroborreliosis is a rare cause of cerebral vasculitis and stroke. The incidence of Lyme borreliosis in Finland has been increasing in the last 20 years, so we expect that Lyme neuroborreliosis-associated vasculitis can be a more common cause of stroke in the future. MATERIALS & METHODS We have retrospectively identified all adult patients (>16 years old) diagnosed with borreliosis (A69.2 Lyme borreliosis), transient ischemic attack (TIA, G45), and ischemic stroke (I63) at Helsinki University Hospital during 1.1.2014-31.10.2019 at our neurological emergency department. Medical data and follow-up data were retrospectively collected from medical records. Neuroborreliosis was diagnosed according to the European Federation of Neurological Societies guidelines. RESULTS We have identified 10 cases of neuroborreliosis-associated stroke or TIA and/or vasculitis. Vasculitis as a manifestation of borreliosis was diagnosed in six patients of 1454 (0.4%) and stroke or TIA in nine (0.6%) of all borreliosis patients at Helsinki University Hospital. Clinical outcomes for all our patients were good with a modified Rankin scale (mRS) 0-2. CONCLUSIONS Lyme neuroborreliosis-associated vasculopathy and cerebrovascular events still remain rare but should be considered especially in Lyme borreliosis endemic areas. Prognosis is good with appropriate antibiotic treatment, but additional immunosupressive treatment is sometimes needed.
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9
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Zubcevik N, Mao C, Wang QM, Bose EL, Octavien RN, Crandell D, Wood LJ. Symptom Clusters and Functional Impairment in Individuals Treated for Lyme Borreliosis. Front Med (Lausanne) 2020; 7:464. [PMID: 32974369 PMCID: PMC7472530 DOI: 10.3389/fmed.2020.00464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/13/2020] [Indexed: 11/17/2022] Open
Abstract
Context: Persistent fatigue, pain, and neurocognitive impairment are common in individuals following treatment for Lyme borreliosis (LB). Poor sleep, depression, visual disturbance, and sensory neuropathies have also been reported. The cause of these symptoms is unclear, and widely accepted effective treatment strategies are lacking. Objectives: To identify symptom clusters in people with persistent symptoms previously treated for LB and to examine the relationship between symptom severity and perceived disability. Methods: This was a retrospective chart review of individuals with a history of treatment of LB referred to The Dean Center for Tick-Borne Illness at Spaulding Rehabilitation Hospital between 2015 and 2018 (n = 270) because of persistent symptoms. Symptoms and functional impairment were collected using the General Symptom Questionnaire-30 (GSQ-30), and the Sheehan Disability Scale. Clinical tests were conducted to evaluate for tick-borne co-infections and to rule out medical disorders that could mimic LB symptomatology. Exploratory factor analysis was performed to identify symptom clusters. Results: Five symptom clusters were identified. Each cluster was assigned a name to reflect the possible underlying etiology and was based on the majority of the symptoms in the cluster: the neuropathy symptom cluster, sleep-fatigue symptom cluster, migraine symptom cluster, cognitive symptom cluster, and mood symptom cluster. Symptom severity for each symptom cluster was positively associated with global functional impairment (p < 0.001). Conclusion: Identifying the interrelationship between symptoms in post-treatment LB in a cluster can aid in the identification of the etiological basis of these symptoms and could lead to more effective symptom management strategies. Key Message: This article describes symptom clusters in individuals with a history of Lyme borreliosis. Five clusters were identified: sleep-fatigue, neuropathy, migraine-like, cognition, and mood clusters. Identifying the interrelationship between symptoms in each of the identified clusters could aid in more effective symptom management through identifying triggering symptoms or an underlying etiology.
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Affiliation(s)
- Nevena Zubcevik
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Invisible International, Cambridge, MA, United States
| | - Charlotte Mao
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Massachusetts General Hospital, Department of Pediatric Infectious Diseases, Boston, MA, United States
| | - Qing Mei Wang
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Eliezer L Bose
- Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Rose Nadlyne Octavien
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - David Crandell
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Lisa J Wood
- Massachusetts General Hospital, Institute for Health Professions, School of Nursing, Charlestown, MA, United States.,William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, United States
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10
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Cervantes-Arslanian AM, Anand P. Infectious Vasculitides of the Central Nervous System. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00815-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP, Krause A, Ruf B, Dersch R. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc03. [PMID: 32341686 PMCID: PMC7174852 DOI: 10.3205/000279] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis. This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults. Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany). The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.
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Affiliation(s)
| | | | | | - Volker Fingerle
- German Society for Hygiene and Microbiology (DGHM), Münster, Germany
| | - Hans-Iko Huppertz
- German Society of Paediatrics and Adolescent Medicine (DGKJ), Berlin, Germany.,German Society of Paediatric Infectology (DGPI), Berlin, Germany
| | - Klaus-Peter Hunfeld
- The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL), Bonn, Germany.,INSTAND e.V., Düsseldorf, Germany
| | | | - Bernhard Ruf
- German Society of Infectious Diseases (DGI), Berlin, Germany
| | - Rick Dersch
- German Society of Neurology (DGN), Berlin, Germany.,Cochrane Germany, Faculty of Medicine, University of Freiburg, Germany
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12
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Ködel U, Fingerle V, Pfister HW. [Lyme neuroborreliosis]. MMW Fortschr Med 2020; 162:44-48. [PMID: 32072526 DOI: 10.1007/s15006-020-0160-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Uwe Ködel
- Neurologische Klinik und Poliklinik, Klinikum Großhadern, Ludwig-Maximilians-Univ., Marchioninistr. 15, D-81377, München, Deutschland
| | - Volker Fingerle
- Nationales Referenzzentrum für Borrelien, Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit, Oberschleißheim, Deutschland
| | - Hans-Walter Pfister
- Neurologische Klinik und Poliklinik, Klinikum Großhadern, Ludwig-Maximilians-Univ., Marchioninistr. 15, D-81377, München, Deutschland.
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13
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Rauer S, Kastenbauer S, Fingerle V, Hunfeld KP, Huppertz HI, Dersch R. Lyme Neuroborreliosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:751-756. [PMID: 30573008 PMCID: PMC6323132 DOI: 10.3238/arztebl.2018.0751] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 06/15/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The new German S3 guideline on Lyme neuroborreliosis is intended to provide physicians with scientifically based information and recommendations on the diagnosis and treatment of this disease. METHODS The scientific literature was systematically searched and the retrieved publications were assessed at the German Cochrane Center (Deutsches Cochrane Zentrum) in Freiburg in the 12 months beginning in March 2014. In addition to the main search terms "Lyme disease," "neuroborreliosis," "Borrelia," and "Bannwarth," 28 further terms relating to neurological manifestations of the disease were used for the search in the Medline and Embase databases and in the Cochrane Central Register of Controlled Trials. RESULTS In the treatment of early Lyme neuroborreliosis, orally administered doxycycline is well tolerated, and its efficacy is equivalent to that of intravenously administered beta-lactam antibiotics (penicillin G, ceftriaxone, and cefotaxime) (relative risk [RR]: 0.98, 95% confidence interval [CI]: [0.68; 1.42], P = 0.93). 14 days of treatment suffice for early Lyme neuroborreliosis, and 14-21 days of treatment usually suffice for late (chronic) Lyme neuroborreliosis. CONCLUSION Lyme neuroborreliosis has a favorable prognosis if treated early. The long-term administration of antibiotics over many weeks or even months for putative chronic Lyme neuroborreliosis with nonspecific symptoms yields no additional benefit and carries the risk of serious adverse effects.
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Affiliation(s)
- Sebastian Rauer
- Department of Neurology and Neurophysiology, Medical Center—University of Freiburg
| | | | - Volker Fingerle
- National Reference Centre for Borrelia, Bavarian Health and Food Safety Authority, Oberschleissheim
| | - Klaus-Peter Hunfeld
- Institute for Laboratory Medicine, Microbiology and Hospital Hygiene, Krankenhaus Nordwest, Frankfurt/Main
| | - Hans-Iko Huppertz
- Klinikum Bremen Mitte, Prof.-Hess-Kinderklinik and Clinic for Pediatric Intensive Care, Bremen
| | - Rick Dersch
- Evidence in Medicine / Cochrane Germany, Medical Center, Faculty of Medicine, University of Freiburg
| | - for the guideline group*
- *All of the editors, authors, and processors of the German S3 guideline on Lyme neuroborreliosis are listed in the eBox.
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14
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Schellekens MMI, van Alebeek ME, Arntz RM, Synhaeve NE, Maaijwee NAMM, Schoonderwaldt HC, van der Vlugt MJ, van Dijk EJ, Rutten-Jacobs LCA, de Leeuw FE. Prothrombotic factors do not increase the risk of recurrent ischemic events after cryptogenic stroke at young age: the FUTURE study. J Thromb Thrombolysis 2018; 45:504-511. [PMID: 29480382 PMCID: PMC5889776 DOI: 10.1007/s11239-018-1631-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The role of hypercoagulable states and preceding infections in the etiology of young stroke and their role in developing recurrent ischemic events remains unclear. Our aim is to determine the prevalence of these conditions in patients with cryptogenic stroke at young age and to assess the long-term risk of recurrent ischemic events in patients with and without a hypercoagulable state or a recent pre-stroke infection with Borrelia or Syphilis. PATIENTS AND METHODS We prospectively included patients with a first-ever transient ischemic attack or ischemic stroke, aged 18-50, admitted to our hospital between 1995 and 2010. A retrospective analysis was conducted of prothrombotic factors and preceding infections. Outcome was recurrent ischemic events. RESULTS Prevalence of prothrombotic factors did not significantly differ between patients with a cryptogenic stroke and with an identified cause (24/120 (20.0%) and 32/174 (18.4%) respectively). In patients with a cryptogenic stroke the long-term risk [mean follow-up of 8.9 years (SD 4.6)] of any recurrent ischemic event or recurrent cerebral ischemia did not significantly differ between patients with and without a hypercoagulable state or a recent infection. In patients with a cryptogenic stroke 15-years cumulative risk of any recurrent ischemic event was 24 and 23% in patients with and without any prothrombotic factor respectively. CONCLUSIONS The prevalence of prothrombotic factors and preceding infections did not significantly differ between stroke patients with a cryptogenic versus an identified cause of stroke and neither is significantly associated with an increased risk of recurrent ischemic events after cryptogenic stroke.
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Affiliation(s)
- Mijntje M I Schellekens
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Mayte E van Alebeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Renate M Arntz
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Nathalie E Synhaeve
- Department of Neurology, Elisabeth Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Noortje A M M Maaijwee
- Center for Neurology and Neurorehabilitation, Luzern State Hospital, Spitalstrasse 31, 6000, Luzern 16, Switzerland
| | - Hennie C Schoonderwaldt
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - Ewoud J van Dijk
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, RadboudUMC, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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15
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Monteventi O, Steinlin M, Regényi M, Roulet-Perez E, Weber P, Fluss J. Pediatric stroke related to Lyme neuroborreliosis: Data from the Swiss NeuroPaediatric Stroke Registry and literature review. Eur J Paediatr Neurol 2018; 22:113-121. [PMID: 29208342 DOI: 10.1016/j.ejpn.2017.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 10/09/2017] [Accepted: 10/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cerebrovascular complications of Lyme neuroborreliosis (LNB) are poorly documented in the paediatric population. METHODS We performed a retrospective analysis from prospectively registered cases of acute ischemic stroke (AIS) from the Swiss NeuroPaediatric Stroke Registry (SNPSR) from 2000 to 2015. Only cases with serologically confirmed LNB were included. In addition, a literature review on paediatric stroke cases secondary to Lyme neuroborreliosis in the same time frame was performed. RESULTS 4 children out of 229 children with arterial ischemic childhood stroke and serologically confirmed LNB were identified in the SNPSR giving a global incidence of 1.7%. Median age was 9.9 years. A prior history of tick bites or erythema migrans (EM) was reported in two cases. Clinical presenting signs were suggestive of acute cerebellar/brainstem dysfunction. On imaging, three children demonstrated a stroke in the distribution of the posterior inferior cerebellar artery. The remaining fourth child had a "stroke-like" picture with scattered white matter lesions and a multifocal vasculitis with prominent basilar artery involvement. Lymphocytic pleocytosis as well as intrathecal synthesis of Borrelia burgdorferi antibodies were typical biological features. Acute intravenous third generation cephalosporins proved to be effective with rapid improvement in all patients. No child had recurrent stroke. Data from the literature concerning eight patients gave similar results, with prominent posterior circulation stroke, multifocal vasculitis and abnormal CSF as distinctive features. CONCLUSIONS Lyme Neuroborreliosis accounts for a small proportion of paediatric stroke even in an endemic country. The strong predilection towards posterior cerebral circulation with clinical occurrence of brainstem signs associated with meningeal symptoms and CSF lymphocytosis are suggestive features that should rapidly point to the diagnosis. This can be confirmed by appropriate serological testing in the serum and CSF. Clinicians must be aware of this rare neurological complication of Lyme disease that demands specific antibiotic treatment.
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Affiliation(s)
- O Monteventi
- Pediatric Neurology Unit, Pediatrics Subspecialities Service, Geneva Children's Hospital, Switzerland
| | - M Steinlin
- Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital Bern, Switzerland
| | - M Regényi
- Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital Bern, Switzerland
| | - E Roulet-Perez
- Pediatric Neurology and Neurorehabilitation Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - P Weber
- University Children's Hospital Basel, Division of Neuropediatrics and Developmental Medicine, Basel, Switzerland
| | - J Fluss
- Pediatric Neurology Unit, Pediatrics Subspecialities Service, Geneva Children's Hospital, Switzerland.
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16
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Ischemic Stroke: Do Not Forget Lyme Neuroborreliosis. Case Rep Neurol Med 2018; 2018:1720725. [PMID: 29805824 PMCID: PMC5899873 DOI: 10.1155/2018/1720725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/01/2018] [Accepted: 02/26/2018] [Indexed: 11/25/2022] Open
Abstract
Lyme neuroborreliosis is a rare cause of ischemic stroke; it has only been described in case reports and mostly in Europe. Diagnostic criteria have been proposed for Lyme neuroborreliosis but the association with a cerebral ischemic presentation is not always straightforward. We here describe the case of an 83-year-old man for whom we strongly suspect Lyme neuroborreliosis as the etiology of his stroke. This case reminds us of the importance of a thorough history taking (i.e., tick bite) and to perform the adequate ancillary tests accordingly (lumbar puncture) so as to propose validated treatment.
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17
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Kortela E, Hytönen J, Numminen J, Overmyer M, Saxen H, Oksi J. Cerebral vasculitis and intracranial multiple aneurysms in a child with Lyme neuroborreliosis. JMM Case Rep 2017; 4:e005090. [PMID: 29026617 PMCID: PMC5630958 DOI: 10.1099/jmmcr.0.005090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/20/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction. Lyme borreliosis is a multisystem tick-borne disease caused by Borrelia burgdorferi. Neurological manifestations are reported in up to 15 % of adult patients with Lyme disease, while the frequency among children is higher. The most common manifestations are painful radiculopathy, facial nerve paresis and lymphocytic meningitis. Epileptic seizures and cerebral vasculitis with stroke or aneurysms are very rare complications. Case presentation. We describe a paediatric patient with sensorineural auditory dysfunction, headache, fatigue and epileptic seizures as sequelae of meningoencephalitis/Lyme neuroborreliosis (LNB) caused by B. burgdorferi. Brain magnetic resonance imaging revealed widespread enhancement of the leptomeninges, cranial nerves and artery walls compatible with vasculitis and disturbances in cerebrospinal fluid (CSF) circulation. The patient was treated with ceftriaxone for 2 weeks. Two years later, the patient had an ischemic stroke. Brain magnetic resonance angiography revealed multiple aneurysms, which were not present previously. The largest aneurysm was operated rapidly. The patient was treated with another course of intravenous ceftriaxone for 4 weeks and pulse therapy with corticosteroids. He recovered well.
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Affiliation(s)
- Elisa Kortela
- Division of Infectious Diseases, Faculty of Medicine, University of Turku, University of Helsinki, Helsinki University Hospital, P.O. Box 348, 00029 HUS, Finland
| | - Jukka Hytönen
- Department of Medical Microbiology and Immunology and Microbiology and Genetics Department, University of Turku, Turku University Hospital, Turku, Finland
| | - Jussi Numminen
- Helsinki Medical Imaging Centre, University of Helsinki, Helsinki, Finland
| | - Margit Overmyer
- Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Harri Saxen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jarmo Oksi
- Department of Infectious Diseases, Division of Medicine, Faculty of Medicine, University of Turku, Turku University Hospital, P.O. Box 52, 20521 Turku, Finland
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18
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Garkowski A, Zajkowska J, Zajkowska A, Kułakowska A, Zajkowska O, Kubas B, Jurgilewicz D, Hładuński M, Łebkowska U. Cerebrovascular Manifestations of Lyme Neuroborreliosis-A Systematic Review of Published Cases. Front Neurol 2017; 8:146. [PMID: 28473801 PMCID: PMC5397664 DOI: 10.3389/fneur.2017.00146] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/31/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) is a disease caused by spirochete Borrelia burgdorferi, involving the nervous system. It usually manifests as lymphocytic meningoradiculitis, but in rare cases, it can also lead to cerebrovascular complications. We aimed to perform a systematic review of all reported cases of LNB complicated by central nervous system vasculitis and stroke or transient ischemic attack (TIA). MATERIALS AND METHODS We conducted a systematic review of literature between May 1987 and December 2016 with patients who presented with cerebrovascular course of LNB. RESULTS This study included 88 patients with a median age of 46 years. The median interval from onset of symptoms suggesting Lyme disease to first symptoms of cerebrovascular manifestations of LNB was 3.5 months. The most common cerebrovascular manifestation of LNB was ischemic stroke (76.1%), followed by TIA (11.4%). The posterior circulation was affected alone in 37.8% of patients, the anterior circulation in 24.4% of patients, and in 37.8% of cases, posterior and anterior circulations were affected simultaneously. The most common affected vessels were middle cerebral artery-in 19 cases, basilar artery-in 17 cases, and anterior cerebral artery-in 16 cases. A good response to antibiotic treatment was achieved in the vast number of patients (75.3%). The overall mortality rate was 4.7%. CONCLUSION Cerebral vasculitis and stroke due to LNB should be considered, especially in patients who live in or have come from areas with high prevalence of tick-borne diseases, as well as in those without cardiovascular risk factors, but with stroke-like symptoms of unknown cause.
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Affiliation(s)
- Adam Garkowski
- Department of Radiology, Medical University of Białystok, Białystok, Poland
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Agata Zajkowska
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Alina Kułakowska
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Olga Zajkowska
- Faculty of Applied Informatics and Mathematics, Warsaw University of Life Sciences SGGW, Warsaw, Poland
| | - Bożena Kubas
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Dorota Jurgilewicz
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Marcin Hładuński
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Urszula Łebkowska
- Department of Radiology, Medical University of Białystok, Białystok, Poland
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19
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Pisché G, Koob M, Wirth T, Quenardelle V, Lagha-Boukbiza O, Renaud M, Anheim M, Tranchant C. Subacute parkinsonism as a complication of Lyme disease. J Neurol 2017; 264:1015-1019. [PMID: 28349210 DOI: 10.1007/s00415-017-8472-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Guillaume Pisché
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Meriam Koob
- Department of Radiology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Thomas Wirth
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Véronique Quenardelle
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Ouhaïd Lagha-Boukbiza
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Mathilde Renaud
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Mathieu Anheim
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Christine Tranchant
- Department of Neurology, CHRU Strasbourg, 1 Avenue Molière, 67098, Strasbourg Cedex, France.
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20
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Topakian R, Artemian H, Metschitzer B, Lugmayr H, Kühr T, Pischinger B. Dramatic response to a 3-week course of ceftriaxone in late neuroborreliosis mimicking atypical dementia and normal pressure hydrocephalus. J Neurol Sci 2016; 366:146-148. [PMID: 27288794 DOI: 10.1016/j.jns.2016.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/01/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - Herta Artemian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - Bettina Metschitzer
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - Herbert Lugmayr
- Institute of Radiology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - Thomas Kühr
- Department of Internal Medicine IV, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - Barbara Pischinger
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
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21
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Abstract
A wide range of infections (virus, bacteria, parasite and fungi) may cause cerebral vasculitides. Headache, seizures, encephalopathy and stroke are common forms of presentation. Infection and inflammation of intracranial vessels may cause pathological vascular remodelling, vascular occlusion and ischemia. Vasculitis in chronic meningitis may cause ischemic infarctions, and is associated with poor outcome. Appropriate neuroimaging (CT-angiography, MR-angiography, conventional 4-vessel angiography) and laboratory testing (specific antibodies in blood and CSF, CSF culture and microscopy) and even brain biopsy are needed to quickly establish the aetiology. Enhancement of contrast, wall thickening and lumen narrowing are radiological signs pointing to an infectious vasculitis origin. Although corticosteroids and prophylactic antiplatelet therapy have been used in infectious cerebral vasculitis, there are no randomized clinical trials that have evaluated their efficacy and safety. Stable mycotic aneurysms can be treated with specific antimicrobial therapy. Endovascular therapy and intracranial surgery are reserved for ruptured aneurysms or enlarging unruptured aneurysms.
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Affiliation(s)
- Francisco Javier Carod Artal
- a Neurology Department , Raigmore hospital , Inverness , UK.,b Health Sciences Faculty , Universitat Internacional de Catalunya (UIC) , Barcelona , Spain
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22
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Stroke as an Unusual First Presentation of Lyme Disease. Case Rep Neurol Med 2015; 2015:389081. [PMID: 26788385 PMCID: PMC4695636 DOI: 10.1155/2015/389081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 12/07/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction. Lyme neuroborreliosis is a nervous system infection caused by spirochete Borrelia burgdorferi with diverse neurological complications. Stroke due to cerebral vasculitis is a rare consequence of neuroborreliosis and has been described in just a few case reports. Case Presentation. Here, we report the case of a 43-year-old patient who presented with discrete left-sided hemiparesis and amnestic cognitive impairment. Brain magnetic resonance imaging showed a thalamic infarct, and serological and cerebrospinal fluid (CSF) tests confirmed the diagnosis of active neuroborreliosis. The antibiotic treatment with intravenous ceftriaxone for three weeks led to an improvement of the symptoms and remarkable regression of radiological findings, but not to full recovery of the amnestic cognitive disorder. Conclusion. Lyme neuroborreliosis should be suspected in patients with cerebrovascular events without obvious risk factors, especially those living in endemic areas such as northern Europe or those who have been exposed to ticks and those with clinical or radiological findings suggesting Lyme neuroborreliosis, in order to establish the diagnosis and start a proper antibiotic therapy.
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