Exploring Cerebrovascular Manifestations of Neuroborreliosis: A Scoping Review

Lyme disease is zoonotic infection transmitted by Borrelia burgdorferi and, if left undiagnosed, can present in later stages with neurological manifestations. This review aims to consolidate evidence on stroke-like or similar cerebrovascular outcomes of Lyme neuroborreliosis (LNB) to aid early recognition and treatment.

A comprehensive search resulted in 90 patients meeting European Federation of Neurological Societies/Infectious Diseases Society of America/ American Academy of Neurology/American College of Rheumatology (EFNS/IDSA/AAN/ACR) criteria for LNB with radiologically or serologically confirmed cerebrovascular involvement. Data were charted descriptively.

Median age was 12 years among children and 52 years in adult cases. Tick exposure was reported in 89% of cases. Presentations included hemiparesis (51%), cranial-nerve palsy (38%; Lower Motor Neuron (LMN) facial 31%), and cognitive changes (26%). Common imaging findings were vasculitis (72%) and ischaemic stroke (51%), mainly in the cortical (56%) area. Cerebrospinal fluid (CSF) lymphocytic pleocytosis (median 73 cells/µL) with presence of intrathecal Borrelia Immunoglobulin G (IgG) appeared in the majority of cases. Antibiotics (mainly ceftriaxone) were used in 85% of cases and interventional management in 13% of cases. Ninety percent of cases improved after 6 months of treatment. Mortality and persistent tetraplegia were reported in 5% and 3% of cases, respectively.

LNB should be suspected in cases of cryptogenic stroke from endemic areas. Reduction in CSF pleocytosis with intrathecal Borrelia antibodies could predict a favorable antibiotic response, although some refractory cases were observed to improve only with interventional management. Prompt diagnosis and management can affect morbidity and mortality.