Patients with breakthrough tick-borne encephalitis suffer a more severe clinical course and display extensive magnetic resonance imaging changes.

To our knowledge, this is the first study systematically describing the peculiarities of MRI in patients vaccinated against TBE. In addition to a severe clinical course, they exhibit more extensive MRI lesions than a non-vaccinated cohort. Possible reasons for these findings include incomplete seroconversion, more virulent TBEV strains or antibody-dependent enhancement.