Lyme Neuroborreliosis MRI: What Standard Scans May Miss
MRI may appear normal in early Lyme neuroborreliosis
¹H-MRS can detect changes in cerebral metabolism
Normal structural imaging does not necessarily exclude neurologic involvement
Lyme neuroborreliosis MRI scans may appear normal even when patients have neurologic involvement. A small study found that proton magnetic resonance spectroscopy (¹H-MRS) detected metabolic brain changes that were not visible on conventional MRI.
This raises an important clinical concern: patients with Lyme disease symptoms may report neurologic complaints even when conventional brain imaging appears normal.
The authors conducted a study to determine whether ¹H-MRS could identify metabolic changes in patients with early Lyme neuroborreliosis when standard MRI showed no visible structural abnormalities.
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, ranging in age from 19 to 65 years. All participants underwent brain imaging using conventional MRI and ¹H-MRS either before or at the start of antibiotic treatment.
Unlike standard MRI, which primarily evaluates the structure of the brain, ¹H-MRS measures concentrations of certain metabolites within brain tissue.
Metabolic Brain Changes in Early Lyme Neuroborreliosis
The ¹H-MRS testing revealed a significant reduction in the ratio of N-acetylaspartate to creatine (NAA/Cr) in several areas of the frontal lobes. N-acetylaspartate is commonly used as a marker of neuronal integrity.
The authors suggested that the reduction was “likely caused by neuronal injury due to Borrelia burgdorferi infection.”
Importantly, these metabolic abnormalities occurred in brain tissue that appeared normal on conventional MRI.
The researchers concluded that the reduced NAA/Cr ratio could reflect neuronal dysfunction or early neuronal damage without visible structural abnormalities. They described these findings as possible latent encephalopathic changes that conventional MRI could not detect.
Why MRI May Miss Early Neurologic Changes
Conventional MRI is designed primarily to detect structural abnormalities, including inflammation, lesions, bleeding, tumors, and changes in brain anatomy.
Magnetic resonance spectroscopy evaluates biochemical and metabolic activity within selected areas of the brain. These metabolic changes may occur before an abnormality becomes structurally visible on MRI.
This difference may help explain why some patients experience cognitive or neurologic symptoms, including brain fog in Lyme disease, despite having a normal MRI report.
Clinical Implications for Lyme Neuroborreliosis
This study suggests that normal conventional MRI findings do not necessarily exclude metabolic brain changes in patients with early Lyme neuroborreliosis.
However, the findings come from a relatively small study. ¹H-MRS is not routinely used as a stand-alone diagnostic test for Lyme neuroborreliosis, and additional research is needed to determine how these findings relate to symptoms, treatment response, and long-term recovery.
Longitudinal testing would be particularly useful to determine whether the metabolic abnormalities improve after treatment and whether changes in ¹H-MRS findings correspond with clinical recovery.
Frequently Asked Questions
Can Lyme neuroborreliosis appear normal on MRI?
Yes. Conventional MRI may appear normal in some patients with Lyme neuroborreliosis because it primarily detects structural abnormalities. This study found metabolic changes with ¹H-MRS in brain tissue that appeared normal on MRI.
What is ¹H-MRS?
Proton magnetic resonance spectroscopy, or ¹H-MRS, is an imaging technique that measures certain chemicals and metabolites within tissue. It can provide information about cerebral metabolism that is not available from a conventional structural MRI.
Does a normal MRI rule out neurologic Lyme disease?
No. A normal MRI does not by itself rule out Lyme neuroborreliosis. Diagnosis depends on the patient’s clinical presentation and may include neurologic examination, Lyme disease testing, cerebrospinal fluid evaluation, and consideration of other possible causes.
Clinical Takeaway
Conventional MRI and ¹H-MRS evaluate different aspects of the brain. A structurally normal MRI does not necessarily mean that cerebral metabolism is normal.
In this study, ¹H-MRS identified metabolic brain changes in patients with early Lyme neuroborreliosis even though conventional MRI showed no visible structural abnormalities.
This article is for informational purposes and is not a substitute for medical advice, diagnosis, or treatment.
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References
- Garkowski A, Kubas B, Hładuński M, et al. Neuronal loss or dysfunction in patients with early Lyme neuroborreliosis: a proton magnetic resonance spectroscopy study of the brain. Journal of Neurology. 2019;266:1937–1943.
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
I think my brain is affected from Lyme and rmsf and Ehrlichlosis
You should see a doctor.
Im on my 19th day of antibiotics, here in Arkansas there is a huge debate over the treatment and diagnosis. I have had the rashes for wel over 5 years and they are still present. Im afraid the damage is already done, but if there is a way to use my data for progression against what is a terrible disease to live with please contact me.
My Dr has not ordered any test other than confirmation and I fear that im going to be swept under the rug.
36 year old white male no history of mental ilnes
I have held a job since i was 15 now I can barely go grocery shoping most days,
Funy how Ive always ben able to do for myself and now I pray for a miracle that may never come. This is no quality of life