1H-MRS Early Lyme Neuroborreliosis: Brain Injury Missed by MRI

1H-MRS early Lyme neuroborreliosis may reveal neurologic damage that is not visible on standard MRI scans.

This raises an important clinical concern: patients with
Lyme disease symptoms can include neurologic complaints even when conventional imaging appears normal.

The authors conducted a study to determine whether 1H-MRS early Lyme neuroborreliosis
could identify neurologic damage in patients when MRI failed to do so. Proton magnetic
resonance spectroscopy (¹H-MRS) was evaluated as a tool to detect subtle brain changes in early Lyme
disease that may not be visible on conventional imaging.

Garkowski and colleagues hypothesized that magnetic resonance spectroscopy could assess neurologic
changes in Lyme disease patients by measuring alterations in cerebral metabolism.

Study Design and Patient Population

The study included 26 patients with early Lyme neuroborreliosis (LNB), aged 19 to 65 years.
All participants underwent brain imaging using both MRI and ¹H-MRS either before or at the start of antibiotic treatment.

[bctt tweet=”MRS testing reveals neurologic damage or dysfunction in early Lyme disease patients—even when MRI is normal.” username=”DrDanielCameron”]

Metabolic Brain Changes in Early Lyme Neuroborreliosis

Results from the ¹H-MRS revealed a significant reduction in the brain metabolite
N-acetylaspartate (NAA), a marker of neuronal integrity.

According to the authors, this reduction is “likely caused by neuronal injury due to
Borrelia burgdorferi infection.”

Importantly, these metabolic changes were not visible on standard MRI scans, highlighting
the limitations of conventional imaging in detecting early neurologic injury.

“The reduction of the NAA/Cr ratio may reflect neuronal dysfunction or early neuronal damage
without visible structural abnormalities of the brain, which may signify latent
encephalopathic changes undetectable by MRI in patients with early LNB,”

the authors write.

Why MRI May Miss Early Neurologic Injury

MRI is designed to detect structural abnormalities of the brain. In contrast, magnetic
resonance spectroscopy evaluates biochemical and metabolic changes that can precede
structural injury.

This may explain why patients experience
brain fog in Lyme disease
despite normal MRI findings.

Clinical Implications for Lyme Neuroborreliosis

These findings suggest that metabolic brain injury may occur early in Lyme disease—even when conventional imaging appears normal.

This may help explain persistent symptoms in patients with
post-treatment Lyme disease syndrome (PTLDS).

Clinical perspective: When neurologic symptoms are present but MRI findings are normal, clinicians should consider metabolic brain dysfunction rather than dismissing symptoms as non-organic.

Editor’s note:
It would be helpful to perform ¹H-MRS testing on patients who recover from LNB to determine
whether these neurologic changes are reversible.

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

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