Clinical Neurological Examination Research Articles

Tumoră medulară mascată de comorbidităţi

Comorbidities present in complex cases can frequently hide new diseases, may influence treatment decisions and can augment risks. The nonvalvular atrial fibrillation is a risk factor for inducing stroke, but treated with anticoagulant drugs in a right way atrial fibrillation is not responsible for the onset of all new motor deficits in a patient. The anamnesis, the thorough clinical neurological examination, associated with specific paraclinical diagnosis methods can lead to the right diagnosis, showing, in this specific case presented, a meningioma of the spinal cord localised in the high cervical region, treated by neurosurgery.

Inpatient Neurologic Consultation in Solid Organ Transplant Patients.

A third of solid organ transplant recipients experience neurologic complications after transplantation. In this article the author reviews common and uncommon complications of the perioperative period including stroke and peripheral neuropathy, neurotoxicity associated with immunosuppressant medications such as calcineurin inhibitors, and opportunistic infections that target the nervous system. A careful clinical history, neurologic examination, and medication review are vital in generating a differential diagnosis that will guide diagnostic testing and decisions regarding treatment and management, and early recognition of many disorders is imperative to prevent irreversible neurologic morbidity and death.

Safety of Overnight Switch from Brand-Name to Generic Levetiracetam.

Concerns that antiepileptic brand-to-generic interchange results in disruption of seizure control are widespread. The objective of this study was to evaluate the safety and tolerability of the brand-to-generic levetiracetam switch in patients with focal or generalized epilepsy. A prospective study in patients with primary, cryptogenic or symptomatic epilepsy, who were taking branded levetiracetam and were switched to generic levetiracetam. Patients were consecutively recruited from January 2013 to January 2015. We evaluated efficacy, tolerability and compliance before switching (T0) and after 6 months of therapy (T1). Evaluations were scheduled as follows: baseline, 7 and 15 days, 1, 3 and 6 months. At each visit clinical diary seizures, physical and neurological examination, laboratory parameters and electroencephalogram were evaluated. Fifty-nine patients, equally mixed by sex, were included in the study. Mean age was 26.1 years. Forty-seven per cent of the patients enrolled received levetiracetam as monotherapy. One patient was lost during the follow-up: so at T1 we had 58 patients (28 monotherapy and 30 polytherapy). At T0 and at T1, there was no statistically significant difference in terms of seizure frequency and intensity, occurrence of adverse events, laboratory parameters and electroencephalographic features. Two patients stopped treatment with the generic (both at 3 months after the switch) and restarted therapy with brand levetiracetam because of seizure increase. At the end of the study, the switchback rate was 3.4%. No increase of seizures and adverse effects were observed when branded levetiracetam was interchanged to a generic equivalent. More studies should be conducted with a larger series of patients to confirm these results.

Prevalence of peripheral nervous system complications after major heart surgery.

We evaluated 374 consecutive patients from May 2013 to April 2014 who underwent major cardiac surgery. Each patient had an interview and a neurological clinical examination during the rehabilitation period. Patients with possible peripheral nervous system (PNS) complications underwent further electrodiagnostic tests. Among 374 patients undergoing major heart surgery (coronary artery bypass grafting, valvular heart surgery, ascending aortic aneurysm repair) 23 (6.1 %) developed 34 new PNS complications. We found four brachial plexopathies; four carpal tunnel syndromes; five critical illness neuropathies; three worsening of pre-existing neuropathies; two involvement of X, one of IX and one of XII cranial nerves; three peroneal (at knee), one saphenous, two median (at Struthers ligament), six ulnar (at elbow) mononeuropathies; two meralgia parestheticas. Diabetes is a strong risk factor for PNS complications (p = 0.002); we could not find any other relationship of PNS complications with clinical conditions, demographic data (gender, age) or type of surgical intervention. The mononeuropathies of right arms can be related to ipsilateral vein cannulation; position of body and stretching from chest wall retraction may be the cause of mononeuropathies of left arms (more frequent); the use of saphenous vein and position of the limbs may be the cause of mononeuropathies of the legs; surgical and anesthetical procedures can injure cranial nerves; respiratory failure and infection during the first days after surgery can cause critical illness neuropathies. Careful preoperative assessment and intraoperative management may reduce the risk of long-term PNS complications after cardiac surgery.

A Congenital Spinal Epidermoid Cyst.

A 73-year-old female with unresolved digestive complaints was referred to our department for CT imaging of the abdomen. Unexpectedly, an oval-shaped, well delineated, intramedullary located mass was found in the spinal canal at the level of the vertebra D11 and D12. On CT imaging the mass is hyperdense to CSF, shows intramural calcification and minimal to no contrast enhancement (Fig. 1A). Proximal to the spinal mass there is a longitudinal split in the spinal cord, diastematomyelia, associated with a congenital block vertebra and hemivertebra at the level of D9–D10 (Fig. 1B). There is also an unfused spinous process of D9 and D10, an anatomical variant which is part of the spectrum of spina bifida occulta (Fig. 1C). The patient has no symptoms of low back pain and no abnormalities in the neurological clinical examination. MR imaging is required for further differentiation of the mass and shows a well-defined lesion without perilesional edema, with hyperintense signal on T1 weighted images (Fig. 2A), inhomogeneous, isointense to hypointense signal on T2 weighted images (Fig. 2B) and no significant enhancement after contrast administration. For further differentiation diffusion weighted imaging (Fig. 3A) was performed and revealed diffusion restriction with corresponding low intensity on ADC map (Fig. 3B) in the entire mass, except in the region of calcification. These findings, in association with the spinal malformations (spina bifida, diastematomyelia, block vertebra and hemivertebra) are highly specific for a congenital spinal epidermoid cyst. The diastematomyelia is best shown on the coronal T2 weighted image in Fig. 4.

SOME ASPECTS OF LOW BACK PAIN SYNDROME PATHOGENESIS AND TREATMENT

Objective. To analyze main causes of low back pain using data of clinical neurological and instrumental examinations and results of conservative and surgical treatment of patients. Material and Methods . A total of 405 patients with acute low back pain were examined and treated. Changes in vertebral bone mineral density indicating osteopenia and osteoporosis were revealed in 247 of them. Most patients had bulging disc detected during MRI and CT examinations. Conservative orthopedic treatment was performed in 340, and surgical in 65 patients. Results . Long-term results were evaluated in 35 patients in the surgical treatment group. Complete elimination of pain was registered in 30 of them, while five patients continued to suffer from pain in the trunk and extremities due to osteopenia and osteoporosis. They were treated with alendronates, bisphosphonates, calcium-based drugs, and vitamin D, and showed pain elimination. In the group of surgical treatment, the complete eradication of spinal instability symptoms was reported already the next day after surgery. Pain in extremities disappeared in all patients, though four patients were troubled by hypesthesia of some areas of foot skin, which regressed over time in two, and persisted in the other two patients. Conclusion . The disc prolapse should not justify making a hasty decision on surgical treatment. In the overwhelming majority of cases, conservative orthopedic treatment has a positive effect. The basis of such treatment must be orthopedic immobilization and unloading of the spine, as well as measures for the normalization of bone mineral density. Surgical treatment should be undertaken only after failure of orthopedic treatment and followed by further measures to normalize mineral density of bone structures.

Effects of vitamin B-12 supplementation on neurologic and cognitive function in older people: a randomized controlled trial

Background: Moderate vitamin B-12 deficiency is relatively common in older people. However, there is little robust evidence on the effect of vitamin B-12 supplementation on neurologic and cognitive outcomes in later life.Objective: We investigated whether vitamin B-12 supplementation benefits neurologic and cognitive function in moderately vitamin B-12–deficient older people.Design: We conducted a double-blind, randomized, placebo-controlled trial in 7 general practices in South East England, United Kingdom. Study participants were aged ≥75 y and had moderate vitamin B-12 deficiency (serum vitamin B-12 concentrations: 107–210 pmol/L) in the absence of anemia and received 1 mg crystalline vitamin B-12 or a matching placebo as a daily oral tablet for 12 mo. Peripheral motor and sensory nerve conduction, central motor conduction, a clinical neurologic examination, and cognitive function were assessed before and after treatment.Results: A total of 201 participants were enrolled in the trial, and 191 subjects provided outcome data. Compared with baseline, allocation to vitamin B-12 was associated with a 177% increase in serum concentration of vitamin B-12 (641 compared with 231 pmol/L), a 331% increase in serum holotranscobalamin (240 compared with 56 pmol/L), and 17% lower serum homocysteine (14.2 compared with 17.1 μmol/L). In intention-to-treat analysis of covariance models, with adjustment for baseline neurologic function, there was no evidence of an effect of supplementation on the primary outcome of the posterior tibial compound muscle action potential amplitude at 12 mo (mean difference: −0.2 mV; 95% CI: –0.8, 0.3 mV). There was also no evidence of an effect on any secondary peripheral nerve or central motor function outcome, or on cognitive function or clinical examination.Conclusion: Results of the trial do not support the hypothesis that the correction of moderate vitamin B-12 deficiency, in the absence of anemia and of neurologic and cognitive signs or symptoms, has beneficial effects on neurologic or cognitive function in later life. This trial was registered at www.isrctn.com as ISRCTN54195799.

The almost-invisible perineurioma.

Intraneural perineurioma is a rare, benign slow-growing lesion arising from the perineurial cells that surrounds the peripheral nerve fibers. Typically it presents during childhood and young adulthood as a motor mononeuropathy. MRI plays an essential role in the diagnosis and localization of the lesion, which appears as a fusiform enlargement of the nerve fascicles that enhances intensely with gadolinium. Despite the typical clinical and radiological features, intraneural perineurioma remains largely underdiagnosed because of the lack of familiarity with this entity, but also as a result of technical limitations with conventional MRI that is typically performed as a screening test over a large field of view and without contrast sequences. The purpose of this article is to present the pitfalls and pearls learned from years of experience in the diagnosis and management of this relatively rare condition. Clinical suspicion and detailed neurological examination followed by high-quality electrophysiological studies (EPS) must lead to an adequate preimaging localization of the lesion and narrowing of the imaging area. The use of high-resolution (3-T) MRI combined with gadolinium administration will allow adequate visualization of the internal anatomy of the nerve and help in differentiating other causes of neuropathy. In cases where the lesion is not recognized but clinical suspicion is high, possible errors must be assessed, including the EPS localization, area of imaging, MRI resolution, and slice thickness.

Subacute encephalitis in a child seropositive for alpha-3 subunit of neuronal nicotinic acetylcholine receptors antibody

A previously healthy and developmentally normal 5-year-old boy from Saudi Arabia presented with a 3 mo history of abnormal behavior in the form of hyperactivity, decreased social engagement, episodic aggressiveness, decreased cognitive performance in school, inappropriate laughter and talking to himself, insomnia, tics and other stereotyped behaviors. His clinical neurological examination did not reveal any focal neurological deficits, but a prolonged electroencephalogram showed non-specific slowing over the right hemisphere. A diagnosis of encephalopathy was entertained, and he underwent testing for infectious, toxic, metabolic and mitochondrial disorders. Magnetic resonance imaging of the brain and cerebrospinal fluid studies were all normal. However, a comprehensive evaluation of paraneoplastic antibodies from cerebrospinal fluid demonstrated the presence of antibodies against the alpha-3 subunit of the neuronal nicotinic acetylcholine receptor, a finding also documented by tests from two different laboratories. An extensive diagnostic investigation that included a fludeoxyglucose-positron emission tomography scan for malignancies showed negative results. The patient was treated with plasmapheresis treatments (five ex- changes) that resulted in a significant improvement in his clinical picture. Following his initial treatments, the patient continued to receive monthly infusions of intravenous immunoglobulin. An evaluation at 5.5 mo after initiation of first treatment revealed a considerable improvement of his behavior and language abilities. The patient returned to his school where he has performed satisfactorily. To our knowledge, this is the first report of a child who developed sub-acute cognitive and neurobehavioral re- gression in association with the presence of a serum antibody to a neuronal ganglionic nicotinic acetylcholine receptor and who improved after immunotherapy.

Clinical history for diagnosis of dementia in men: Caerphilly Prospective Study.

Diagnosis of dementia often requires specialist referral and detailed, time-consuming assessments. To investigate the utility of simple clinical items that non-specialist clinicians could use, in addition to routine practice, to diagnose all-cause dementia syndrome. Cross-sectional diagnostic test accuracy study. Participants were identified from the electoral roll and general practice lists in Caerphilly and adjoining villages in South Wales, UK. Participants (1225 men aged 45-59 years) were screened for cognitive impairment using the Cambridge Cognitive Examination, CAMCOG, at phase 5 of the Caerphilly Prospective Study (CaPS). Index tests were a standardised clinical evaluation, neurological examination, and individual items on the Informant Questionnaire for Cognitive Disorders in the Elderly (IQCODE). Two-hundred and five men who screened positive (68%) and 45 (4.8%) who screened negative were seen, with 59 diagnosed with dementia. The model comprising problems with personal finance and planning had an area under the curve (AUC) of 0.92 (95% confidence interval [CI] = 0.86 to 0.97), positive likelihood ratio (LR+) of 23.7 (95% CI = 5.88 to 95.6), negative likelihood ratio (LR-) of 0.41 (95% CI = 0.27 to 0.62). The best single item for ruling out was no problems learning to use new gadgets (LR- of 0.22, 95% CI = 0.11 to 0.43). This study found that three simple questions have high utility for diagnosing dementia in men who are cognitively screened. If confirmed, this could lead to less burdensome assessment where clinical assessment suggests possible dementia.

Neurological symptoms and syndromes in municipal transport drivers

The way the municipal transport drivers perform their job contributes to varied burdens linked with the body posture at work, stress, shift work, vibration, noise and exposure to chemical agents. The aim of the study was to assess the condition of the nervous system (NS) in municipal transport drivers. The study covered 42 men, aged 43.4 years (standard deviation (SD): 8.3), employed as bus drivers in the municipal transport enterprise. The duration of employment was 11.8 years on average (SD: 8.6). The condition of the nervous system was assessed on the basis of clinical neurological examinations. Chronic lumbosacral syndrome was found in 54.8% of the subjects. A significant relationship between the incidence of lumbosacral syndrome and the duration of employment (p=0.032) was observed; significantly higher in drivers employed for 11-15 years (90.9%) in comparison to the remaining groups. Nervous system functional disorders were characterized by the increased emotional irritability (47.6%), sleep disorders manifested by excessive sleepiness (33.3%) or insomnia (28.6%) and headaches (3%), mostly tension headaches. Excessive daytime sleepiness was significantly age-dependent (p=0.038). The evidenced NS disorders indicate the need to undertake preventive measures tailored for the occupational group of bus drivers.

Neurologists׳ accuracy in predicting cognitive impairment in multiple sclerosis

Cognitive impairment affects approximately 40–70% of MS patients. As management of MS typically begins with, and is co-ordinated by neurologists, they are often the first to raise concerns about a patient׳s cognitive functioning. However, it is not known how accurate the neurological examination is in identifying cognitive impairment. To this end, we conducted a retrospective chart review of 97 MS patients referred by neurologists for neuropsychological assessment based on suspected cognitive impairment. Patients were classified as globally-impaired or intact according to failure on 2 or more of 11 cognitive indices comprising the MACFIMS, a recommended neuropsychological battery for MS. Neurologists׳ accuracy was not significantly different from chance, Χ2=1.25, p=0.26, with 44.3% of patients with suspected cognitive impairment showing global impairment on objective testing. Cognitively intact patients when compared to those who were impaired had higher levels of education and were less likely to have mood disturbances. These findings indicate the clinical interview and standard neurological examination are not sufficiently sensitive to detect cognitive impairment in MS, and suggest the need for a brief, accurate cognitive screen to complement routine clinical evaluation.

Treatment of chronic inflammatory demyelinating polyneuropathy.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is one of the acquired demyelinating neuropathies and is considered to be immune mediated. Diagnosis is typically based on clinical history, neurologic examination, electrophysiologic studies, CSF studies, and pathologic examination. Early diagnosis and treatment is important to prevent irreversible axonal loss and optimize improvement in function. The first-line agents for treatment are intravenous immunoglobulin (IVIg), corticosteroids, and plasmapheresis, which have all been demonstrated to be effective in controlled studies. Studies have not shown a significant difference between these three treatments, and the initial choice of therapy is often based on availability, cost, ease of administration, and side effect profile. If patients do not respond to one of these agents, they may respond to one of the others and sometimes in combination. If the first-line agents are not effective, chemotherapeutic or immunosuppressive agents may be considered. There are limited controlled studies of these modalities, and they are often used in conjunction with a first-line treatment. The majority of patients require long-term therapy to maintain a response and to prevent relapse.

Nerve conduction studies in diabetics presymptomatic and symptomatic for diabetic polyneuropathy

ObjectiveWe performed nerve conduction studies (NCS) on diabetics with and without symptoms of diabetic polyneuropathy (DPN) and evaluated correlations with glycaemic control and clinical features. MethodsConsecutive patients were recruited in three groups: “normals” (nondiabetics without peripheral nerve disease); “presymptomatic diabetics” (diabetes without DPN); and “symptomatic diabetics”. Clinical questionnaire and neurological examination were administered, and NCS were performed using standard techniques. Results153 patients were recruited (51 normals, 50 presymptomatic diabetics, 52 symptomatic). Glycosylated haemoglobin and duration of DM were higher in symptomatic diabetics, with symptoms present for 1–60 months (mean 14.5). Alterations in NCS included prolonged latencies, lowered amplitudes and slowed conduction velocities, following a pattern of initially reduced sensory amplitudes and slowed motor velocities, with later reduced motor and sensory amplitudes and prolonged motor latencies. Neuropathic pain, clinical signs and glycosylated haemoglobin correlated with these changes. ConclusionsEven in asymptomatic patients, NCS show diffuse changes, in a predictable pattern. Electrophysiological parameters correlate with neuropathic pain, physical findings and glycosylated haemoglobin levels. SignificanceWe demonstrate that NCS changes in DPN follow a predictable pattern, correlating with clinical features and long-term glycaemic control.

Эффективность комплексной нейрометаболической терапии у больных с первичным и повторным мозговым ишемическим полушарным инсультом

Для изучения эффективности комбинированной нейропротекторной терапии с применением препаратов Цераксон® и Актовегин в остром периоде первичного и повторного мозгового ишемического полушарного инсульта было проведено комплексное клинико-неврологическое и нейропсихологическое обследование 186 больных в возрасте от 45 до 85 лет. Комбинированное нейропротекторное, нейрометаболическое, ангиопротекторное, антиоксидантное, нейротрофическое действие препаратов Цераксон® и Актовегин способствовало более активному регрессированию неврологического и когнитивного дефицита, улучшению клинико-социального исхода острого периода заболевания. Сочетанное применение данных препаратов доказало свое превосходство над мононейропротекторной терапией.

Correlation of self-reported Leeds assessment of neuropathic symptoms and signs, clinical neurological examination and MRI findings in diagnosing lumbo-sacral radiculopathy

Correlation of self-reported Leeds assessment of neuropathic symptoms and signs, clinical neurological examination and MRI findings in diagnosing lumbo-sacral radiculopathy

P108 – 2408: Use of the cranial computed tomography in children with acute neurological complaints at the Pediatric Emergency Department

Objective The objective of this study is to determine the prevalance, indications, aid to the diagnosis and the treatment and the excessive and irrelevant use of the cranial computed tomography (CCT) in children with acute neurological complaints. Methods The records of the patients, who presented to Pediatric Emergency Department of Gazi University Medical Faculty between June 2012 to June 2013 with acute neurological complaints and had CCT, were reviewed retrospectively. Results During one year, 34.575 patients were admitted to our emergency department. Ranging in age from one month to eighteen years, 146 girls and 240 boys, 460 had CCT scan, 386 patients were included. The indications for CCT are trauma 78.4%, seizure 6.9%, unconsciousness 4.1%, headache 3.1% and the others 7.2% respectively. The results of CCT scans of 156 40.4% were reported abnormal (110 of these patients have significant findings such as brain edema, fractures and/or haemorrhage). MRI scan was performed to 27 of these patients who has normal CCT, 11 of them parenchymal haemorrhage, axonal damage, mass, sinusitis, ventricular dilatation and gliotic signal changes were reported. Only 120 (31%) patients were hospitalized and 11 (2.8%) of them had emergent neurosurgical intervention. Conclusion Although CCT is still commonly used in the evaluation of acute neurological conditions at pediatric emergency departments, the number of patients who have urgent neurosurgical intervention is very low. As a result, if CCT scan is not supported with clinical findings and neurological examination, the use of CCT scan can be excessive and irrelevant.

The role of color Duplex in diagnosing chronic cerebrospinal venous insufficiency in patients with multiple sclerosis

IntroductionCCSVI, has been recently hypothesized to play a role in the etiology of MS. It can be reliably assessed using Doppler sonography by evaluating the extra cerebral venous hemodynamics with changes in posture. Aim of studyTo evaluate the prevalence of CCSVI in patients with MS. Patients and methodsA total of 60 patients were studied; (52) with relapsing–remitting MS, (4) with primary progressive MS and (4) with secondary progressive MS. Sixty healthy age and gender-matched controls were enrolled in this study.Patients were subjected to full clinical history, neurological examination and Doppler ultrasound assessment. ResultsCCSVI defined as the presence of at least two positive venous hemodynamic criteria and was present in 8 of the 60 MS patients (13%) and was not found at any of the 60 controls (0%). Four patients showed the full 4 criteria for diagnosis while the other 4 patients only showed 2 criteria. CCSVI was noticed more to be frequent among SP and PP patients (25% and 25% respectively) in respect of RR MS (50%) and showing high significant value. ConclusionWe conclude that CCSVI is an unlikely cause of MS and it is likely to be a late secondary phenomenon.

Functional outcome, cognition and quality of life after out-of-hospital cardiac arrest and therapeutic hypothermia: data from a randomized controlled trial.

BackgroundTo study functional neurologic and cognitive outcome and health-related quality of life (HRQoL) in a cohort of patients included in a randomised controlled trial on glucose control following out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation (VF) treated with therapeutic hypothermia.MethodsPatients alive at 6 months after being discharged from the hospital underwent clinical neurological and extensive neuropsychological examinations. Functional outcome was evaluated with the Cerebral Performance Category scale, the modified Rankin scale and the Barthel Index. Cognitive outcome was evaluated by neuropsychological test battery including two measures of each cognitive function: cognitive speed, execution, memory, verbal skills and visuospatial performance. We also assessed quality of life with a HRQoL 15D questionnaire.ResultsOf 90 OHCA-VF patients included in the original trial, 57 were alive at 6 months. Of these, 52 (91%) were functionally independent and 54 (95%) lived at their previous home. Focal neurological deficits were scarce. Intact cognitive performance was observed in 20 (49%), mild to moderate deficits in 14 (34%) and severe cognitive deficits in 7 (17%) of 41 patients assessed by a neuropsychologist. Cognitive impairments were most frequently detected in executive and memory functions. HRQoL of the CA survivors was comparable to that of age- and gender matched population.ConclusionsFunctional outcome six months after OHCA and therapeutic hypothermia was good in the great majority of the survivors, and half of them were cognitively intact. Of note, the HRQoL of CA survivors did not differ from that of age- and gender matched population.

Peripheral facial palsy as an initial symptom of Lyme neuroborreliosis in an Austrian endemic area.

The objective of this study was to analyze the percentage as well as clinical and laboratory characteristics of Lyme neuroborreliosis (LNB) in patients admitted with peripheral facial palsy. Additionally, we looked for diagnostic criteria to distinguish Bell's palsy from facial palsy due to LNB. Data collection was done retrospectively from 2007 until 2012. We identified 278 consecutive patients, who were admitted to the department of Neurology due to peripheral facial palsy. Patients were routinely investigated for LNB including clinical neurological examination and cerebral spinal fluid (CSF) analysis. Demographic and clinical data were analyzed according to a standardized protocol. In 19 (male (m)=14/female (f)=5) out of 278 patients (7%), a diagnosis of LNB was established. There were 8 patients (3%) identified with varicella zoster (VZV) (m=7/f=1) and 13 patients (5%) with facial palsy due to diabetic mononeuropathy (m=5/f=8). A total of 207 patients (75%) were diagnosed as Bell's palsy (m=110/f=97). Compared with CSF of patients with facial palsy due to VZV and diabetic mononeuropathy, patients with LNB showed higher cell count, protein and lactate levels, whereas patients with facial palsy due to diabetic mononeuropathy showed higher glucose level. With respect to seasonal clustering, an accumulation of 74% of the LNB cases was detected from June to October, whereas in the rest of the year there were only 26% of the LNB cases. Patients with Bell's palsy are more evenly distributed over the year. Regarding neurological signs and symptoms, radicular symptoms were only reported in the LNB group. Despite radicular symptoms for LNB, no specific signs or symptoms were found for facial palsy due to VZV, Bell's palsy, or diabetic mononeuropathy. According to the results of our study, we recommend CSF testing in any case for patients with facial palsy in an endemic area from June to October especially if additional radicular symptoms are present. To establish recommendations for a diagnostic workup in patients with facial palsy in areas endemic for Borrelia, the seasonal clustering of LNB as well as specific clinical features should also be confirmed in a future prospective trial.