Neurology Case Studies with Answers: How to Solve Them and Where to Practice

Neurology is the only medical school subject where a clinical case is solved almost like an equation: symptoms → level of lesion → localization → nosology. Students fail not because of the volume of material, but because they skip the first step and immediately guess the diagnosis. Below is an algorithm, four worked-out case studies, and a simulator containing 90 such cases.

Algorithm: Four questions for any case study

1. Which systems are affected? Motor system (paresis), sensory system, coordination, cranial nerves, higher mental functions, pelvic organs.
2. Central or peripheral? For paresis: spasticity, hyperreflexia, pathological reflexes, no atrophy = central (upper motor neuron); hypotonia, hypo- or areflexia, atrophy, fasciculations = peripheral (lower motor neuron).
3. What is the level of the lesion? Cortex, internal capsule, brainstem (alternating syndromes), spinal cord (dermatomal level, Brown-Séquard syndrome), nerve root, plexus, nerve, neuromuscular junction, muscle.
4. What is the pathological process? Rate of onset: seconds to minutes = vascular; hours to days = inflammatory; weeks to months = tumor, degeneration; fluctuating = demyelinating.

Only after the fourth step should you name the diagnosis. If a case presents with "sudden onset" and "right-sided hemiparesis with central paresis of CN VII and XII" — this is the left internal capsule, a vascular process, and it does not matter that you haven't read about blood pressure yet.

Case 1. Hemiparesis and aphasia

A 67-year-old man with a history of hypertension presented in the morning with an inability to speak and weakness in the right extremities. Consciousness is clear; he understands spoken language and produces individual words with effort. Right-sided hemiparesis, muscle strength 2/5 in the arm and 3/5 in the leg, spastic muscle tone, hyperreflexia on the right, positive Babinski sign on the right. Smoothing of the right nasolabial fold, deviation of the tongue to the right.

Analysis. Right-sided central hemiparesis with central paresis of CN VII and XII → lesion in the left hemisphere above the brainstem. Motor aphasia (understands, cannot speak) → Broca's area, left frontal lobe. The arm is more affected than the leg → cortical localization in the middle cerebral artery (MCA) territory. Sudden onset in a hypertensive patient → ischemic stroke in the left MCA territory. Next step: head CT to rule out hemorrhage, NIHSS score assessment, thrombolysis window is 4.5 hours from symptom onset.

Case 2. Lower back pain radiating to the leg

A 42-year-old woman developed lower back pain after heavy lifting, radiating along the posterolateral aspect of the left thigh and lower leg to the little toe. Reduced sensation on the outer edge of the foot, diminished left Achilles reflex, difficulty standing on tiptoes. Lasegue's sign on the left is positive at 40°.

Analysis. Area of pain and hypesthesia corresponds to the S1 dermatome. Loss of the Achilles reflex (S1–S2 reflex arc) and weakness of plantar flexion → S1 nerve root. Peripheral pattern (hyporeflexia), acute onset following physical load → S1 radiculopathy on the left, likely L5–S1 disc herniation. If the L5 root were affected: pain along the lateral aspect of the lower leg to the big toe, weakness of foot dorsiflexion, Achilles reflex preserved.

Case 3. Evening fatigue and ptosis

A 24-year-old woman: double vision and drooping of the eyelids worsen by evening, almost absent in the morning. She tires with chewing. Reflexes and sensation are normal, no atrophy. After 2 minutes of upward gaze, ptosis progressively worsens.

Analysis. Pathological muscle fatigability, selective involvement of extraocular and bulbar muscles, absence of both central and peripheral signs of paresis → level of the neuromuscular junction. Diagnosis: myasthenia gravis. Confirmation: neostigmine (Proserin) test, anti-acetylcholine receptor antibodies, chest CT (thymoma). A typical student mistake is searching for a brainstem lesion: in myasthenia gravis, pupillary light reactions are preserved, and symptoms fluctuate.

Case 4. Fever and nuchal rigidity

A 19-year-old college student presents with a 2-day history of fever up to 39.5 °C, severe headache, vomiting, and photophobia. Nuchal rigidity and positive Kernig's sign bilaterally. No focal neurological signs. Cerebrospinal fluid (CSF): turbid, cell count 4,800/µL, neutrophils 92%, protein 2.1 g/L, glucose 1.4 mmol/L.

Analysis. Meningeal syndrome without focal signs → meningitis. Neutrophilic pleocytosis, high protein, low glucose → bacterial purulent meningitis; in a dorm resident, the primary suspicion is meningococcal infection. Antibiotics are administered immediately after CSF collection, without waiting for culture results. For comparison: viral meningitis shows lymphocytic pleocytosis in the hundreds, protein up to 1 g/L, and normal glucose. CSF reference ranges can be found in the reference table.

Practice simulator: 90 case studies and 14 interactive tasks

The Neurology Practice Simulator section contains 90 situational case studies divided into 14 topics: sensory system and pathways, motor system, cranial nerves, extrapyramidal system and cerebellum, brainstem and spinal cord, peripheral nervous system, neuromuscular diseases, stroke, epilepsy, headache, neuroinfections, traumatic brain injury and tumors, demyelinating diseases, and cognitive impairment. Each case includes up to three questions that appear sequentially; after answering, an explanation is provided detailing why a particular option is correct.

In addition to problems, there are 14 interactive tasks not found in standard problem books: differentiate signs of central and peripheral paralysis, locate the lesion by clicking on the level scheme from the cortex to the muscle, match alternating syndromes, reflexes, dermatomes, and cranial nerves, calculate the Glasgow Coma Scale, complete a stroke case with a timer, and evaluate cerebrospinal fluid in meningitis.

The simulator is included in the «Neurology» subject on any plan. Without the subject subscription, a demo version is available: one task from each section and three interactive tasks.

Common exam mistakes

• Stating a diagnosis without determining the level of the lesion. The professor will ask «where is the lesion?» — and there will be no answer.
• Confusing the sides: the corticospinal tract decussates at the border of the medulla oblongata and spinal cord, so a lesion above the decussation causes symptoms on the contralateral side, and below it — on the ipsilateral side.
• Forgetting about alternating syndromes: a cranial nerve palsy on the side of the lesion plus hemiparesis on the contralateral side indicates a brainstem lesion and nothing else.
• Ignoring the onset rate: «progressively increasing weakness over six months» cannot be a stroke, regardless of what the topical diagnosis looks like.

Table: central and peripheral paresis

Frequently asked questions

Where can I find the answers to university problem book cases? Authors of problem books usually do not publish answers. The effective approach is to solve the case using the algorithm above and check your logic in the simulator using a similar task, or ask the AI-tutor by providing the problem text.

How many cases do I need to solve before the exam? 3–5 per section with error analysis, meaning 50–70 in total. Doing more without review is not effective.

Is the simulator suitable for the accreditation exam? For general medicine accreditation tasks, there is a dedicated «Cases» section in the accreditation simulator; neurological cases also appear there, and the problem-solving algorithm is the same.

See also: The 12 cranial nerves: table · Stroke: ischemic and hemorrhagic · Meningitis · Neurology reference guide