When Lyme Neuroborreliosis Leads to Recurrent Strokes

RECURRENT STROKES?
WHEN LYME DISEASE
IS MISSED

Lyme neuroborreliosis can rarely trigger cerebral vasculitis and recurrent strokes—even when spinal fluid testing appears normal.

In their article, “A case report of unilateral cerebral vasculitis in adults: keep in mind Lyme neuroborreliosis,” Riescher and colleagues examine the case of a 58-year-old man with recurrent strokes later linked to Lyme neuroborreliosis.

The authors describe “recurrent strokes in the same vascular territory without CSF pleocytosis, reflecting an unusual first manifestation of Lyme neuroborreliosis.”

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Lyme Disease Vasculitis Is Rare—but Important

The authors point out that cerebral vasculitis is reported in only 0.3–1% of Lyme neuroborreliosis cases.

Unilateral or focal vasculitis has only rarely been described and is seen primarily in children.

In this case, the patient had no cardiovascular risk factors or significant medical history.

He initially developed sudden right brachiofacial weakness. Although he partially recovered, facial palsy persisted.

CT angiography of the cervical and intracranial vessels showed no abnormalities.

The patient was diagnosed with a cryptogenic stroke and treated with aspirin, atorvastatin, and perindopril.

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Repeated Strokes Despite Standard Stroke Therapy

Two months later, the patient suddenly developed aphasia.

“Burgdorferi-induced cerebral vasculitis is thought to be a very rare manifestation of Lyme neuroborreliosis. But it must nonetheless be considered in the differential diagnosis of unexplained recurrent and/or multiple strokes.”

MRI revealed a new ischemic lesion in the left MCA territory along with an older lesion in the ACA territory.

Over the following months, additional symptoms developed:

• Paresthesia in the right hand and foot
• Headaches
• Extreme weakness and fatigue
• Psychomotor slowing
• Unsteadiness

Thirteen months after the initial presentation, he developed right leg weakness.

Repeat MRI demonstrated additional ischemic lesions involving the left ACA and MCA territories.

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Lyme Disease Testing Finally Revealed the Cause

Despite repeated neurological events, additional testing remained unrevealing.

However, Lyme disease testing was eventually found to be “highly positive” on ELISA and confirmed by Western blot.

The patient was treated with a one-month course of doxycycline.

“The patient experienced no further stroke after four weeks of doxycycline treatment.”

In the weeks that followed, the patient reported dramatic improvement, including resolution of asthenia, dizziness, and right arm paresthesia.

He later recalled a tick bite two years before the first stroke, accompanied by an erythema migrans rash.

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Why This Case Matters

This case highlights an important diagnostic challenge: Lyme neuroborreliosis may rarely present with recurrent stroke-like events even when spinal fluid findings are normal.

Neurological Lyme disease can mimic vascular, inflammatory, or autoimmune disorders, making diagnosis difficult when clinicians are not considering tick-borne illness.

For more on neurological complications, see stroke associated with Lyme disease and untreated Lyme disease triggering stroke in a child.

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Clinical Takeaway

Lyme neuroborreliosis should be considered in patients with unexplained recurrent strokes, especially when symptoms evolve over time and standard evaluations remain inconclusive.

Even rare manifestations such as Lyme-associated cerebral vasculitis may improve with appropriate antibiotic treatment.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention