Pediatric Stroke in Neuroborreliosis-Associated Cerebral Vasculitis with Significant Left MCA Stenosis: Endovascular and Medication-Based Treatment with Excellent Outcome

Neuroborreliosis is the disseminated form of Lyme borreliosis and refers to the involvement of the central nervous system by Borrelia burgdorferi sensu lato spirochetes. Neurological manifestations in both early and late stages of neuroborreliosis have been documented mainly in European adults. The presence of different clinical manifestations is related to the different spirochete species and the age of the patients. In some rare cases, neuroborreliosis may induce inflammation in the cerebral blood vessels, possibly leading to transient ischemic attacks, ischemic strokes, or intracranial hemorrhages. Several reports indicate its emergence as a potential cause of stroke in children and young adults. A 13-year-old boy was admitted to the emergency department of our hospital because of severe headache and syncopal episodes over a 5-h period. On clinical examination, the patient was intermittently disoriented, was agitated, and had paresis of the right arm and face. The patient was intubated and underwent MRI. The MRI revealed acute ischemia involving the left insular cortex, and time-of-flight angiography showed loss of arterial flow in the left distal middle cerebral artery/M1 segment. Subsequent digital subtraction angiography demonstrated high-grade stenosis in the distal M1 and proximal M2 segments with delayed perfusion of the distal branches. Endovascular intra-arterial milrinone infusion was then performed under general anesthesia, resulting in improved perfusion of the left middle cerebral artery branches. An MRI scan the following day showed diffuse leptomeningeal enhancement consistent with meningitis and arterial wall thickening with contrast enhancement predominantly involving the left middle cerebral artery consistent with multifocal cerebral vasculitis. Ischemic changes within the left insular cortex resolved. A cerebrospinal fluid sample showed pleocytosis and identified borreliosis-specific antibodies. The patient was treated with intravenous antibiotics and steroids. Due to vasculitis and significant stenosis, oral antiplatelet therapy with acetylsalicylic acid and nimodipine was initiated. During hospitalization, the patient’s clinical symptoms improved significantly. Subsequent MRI scans showed reduction of meningeal and vessel wall enhancement and improvement in vessel diameter. The patient made a full recovery and was discharged home. We present a case of cerebral vasculitis in a 13-year-old boy associated with Lyme borreliosis with high-grade left middle cerebral artery stenosis leading to ischemic stroke. Endovascular and medicinal treatment resulted in an excellent clinical outcome.