,CONTENT
Chapter 1: Introduction to Clinical Case Presentations
Chapter 2: Neuroanatomy Overview and Basic Definitions
Chapter 3: The Neurologic Exam as a Lesson in Neuroanatomy
Chapter 4: Introduction to Clinical Neuroradiology
Chapter 5: Brain and Environs: Cranium, Ventricles, and Meninges
Chapter 6: Corticospinal Tract and Other Motor Pathways
Chapter 7: Somatosensory Pathways
Chapter 8: Spinal Nerve Roots
Chapter 9: Major Plexuses and Peripheral Nerves
Chapter 10: Cerebral Hemispheres and Vascular Supply
Chapter 11: Visual System
Chapter 12: Brainstem I: Surface Anatomy and Cranial Nerves
Chapter 13: Brainstem II: Eye Movements and Pupillary Control
Chapter 14: Brainstem III: Internal Structures and Vascular Supply
Chapter 15: Cerebellum
Chapter 16: Basal Ganglia
Chapter 17: Pituitary and Hypothalamus
Chapter 18: Limbic System: Homeostasis, Olfaction, Memory and Emotion
Chapter 19: Higher-Order Cerebral Function
,Chapter 1 — Introduction to Clinical
Case Presentations
Below are 20 multiple-choice questions aligned with Chapter 1: Introduction to
Clinical Case Presentations. Each question has four choices (A–D), the answer
shown exactly as Answer: X, a deep rationale for the correct answer (including
why distractors are wrong), and a small set of key words.
1. What is the best initial cognitive step when you first read a neurologic case
history describing acute-onset unilateral weakness and aphasia?
A. Immediately request MRI brain with diffusion sequences.
B. Formulate a topographical localization hypothesis and a short differential based
on onset and distribution.
C. Start empiric anticoagulation for suspected cardioembolic stroke.
D. Order an EEG to exclude seizure as the cause.
Answer: B
Rationale: The correct first step is to form a localization hypothesis (which
cortical region/vascular territory) and a brief differential guided by timing and
symptom pattern. This frames subsequent choices (urgent CT/MRI, thrombolysis
decisions, labs). Option A is premature without targeted clinical localization and
urgency assessment (though imaging will be needed quickly). Option C is unsafe
without confirmation and stroke subtype assessment. Option D (EEG) is lower
priority for classic stroke presentation and would not be the immediate first step.
Key words: localization hypothesis, onset, differential, prioritization
2. In the book’s case-presentation format (history → exam → imaging →
diagnosis), which advantage is most reliably achieved by delaying imaging
interpretation until after a focused neurologic exam?
A. Minimizes time to definitive therapy.
B. Eliminates need for imaging in most cases.
C. Reduces cognitive bias by forcing independent clinical localization before
image confirmation.
D. Increases diagnostic sensitivity of CT scans.
,Answer: C
Rationale: Delaying interpretation of imaging until after a focused exam helps
reduce confirmation and availability bias — the clinician forms an independent
localization hypothesis and then tests it against imaging. A is false because
delaying imaging may increase time; B is false — imaging remains often
necessary; D is incorrect — imaging sensitivity is unaffected by interpretation
order.
Key words: cognitive bias, independent localization, confirmation bias
3. A patient presents with progressive numbness in a stocking-glove distribution
over months. According to clinical-reasoning principles introduced in Chapter 1,
which conclusion is most consistent to start your diagnostic thinking?
A. Localize the lesion to a single central nervous system focus.
B. Favor a peripheral polyneuropathy and generate systemic/metabolic
differentials.
C. Immediately suspect a brain tumor and schedule neurosurgery.
D. Attribute symptoms to a psychogenic cause because onset is slow.
Answer: B
Rationale: Stocking-glove distribution developing over months is classic for a
peripheral polyneuropathy (e.g., diabetic neuropathy, B12 deficiency). Thus
clinical reasoning should favor systemic/peripheral etiologies. A (single CNS
focus) is unlikely given symmetric distal distribution; C is not supported by
pattern; D is inappropriate without exclusion of organic causes.
Key words: stocking-glove, polyneuropathy, chronic, systemic causes
4. Which pattern of neurologic deficits most strongly suggests a brainstem lesion
rather than a cortical lesion?
A. Pure expressive aphasia without motor signs.
B. Contralateral hemiparesis and hemisensory loss with gaze preference toward the
lesion.
C. Ipsilateral cranial nerve deficits with contralateral long-tract motor or sensory
findings (i.e., “crossed” findings).
D. Progressive isolated memory loss over years.
Answer: C
Rationale: Crossed findings (ipsilateral cranial nerve involvement with
,contralateral limb deficits) are characteristic of brainstem lesions because cranial
nerve nuclei are ipsilateral while long tracts have already decussated or are on the
opposite side. A is cortical; B is more cortical/hemispheric; D suggests
neurodegenerative cortical disease.
Key words: crossed signs, brainstem, cranial nerves, long tracts
5. A 45-year-old with sudden severe headache and neck stiffness is described in a
case history. Following Chapter 1 principles, which immediate imaging modality
best matches the emergent clinical suspicion?
A. Noncontrast CT head to look for subarachnoid hemorrhage.
B. MRI brain with angiography as the first test.
C. Plain skull X-ray.
D. Cervical spine MRI.
Answer: A
Rationale: Sudden severe ("thunderclap") headache with meningeal signs raises
subarachnoid hemorrhage suspicion; noncontrast CT head is the fastest and most
sensitive in the acute window and is the appropriate emergent test. MRI/MRA can
be useful later but is less rapid. Skull X-ray and cervical MRI are irrelevant initial
choices.
Key words: thunderclap headache, SAH, noncontrast CT, emergent imaging
6. Which statement best reflects the concept of “localization of lesions”
emphasized in Chapter 1?
A. Symptoms always map directly and uniquely to single anatomic structures.
B. Localization synthesizes history and exam to identify the most likely anatomical
site(s), recognizing that some presentations may be multifocal or systemic.
C. Localization is obsolete because modern imaging always replaces the exam.
D. Localization only applies to peripheral nervous system disorders.
Answer: B
Rationale: Localization is an integrative skill—using history and exam to
hypothesize anatomical site(s)—while acknowledging limitations:
multifocal/systemic processes and false localizing signs exist. A is too rigid; C is
false — imaging complements but does not replace localization; D is wrong —
localization applies across CNS and PNS.
Key words: integration, hypothesis, multifocal, limits
,7. In the provided case format, what is the major risk of relying on imaging
findings alone without correlating the neurologic exam?
A. Increased healthcare costs only.
B. Overlooking incidental imaging abnormalities (incidentalomas) that do not
explain the clinical syndrome.
C. Complete elimination of diagnostic uncertainty.
D. Increased sensitivity but decreased specificity of the neurologic exam.
Answer: B
Rationale: Relying solely on imaging risks attributing symptoms to incidental
lesions unrelated to the patient’s presentation (incidentalomas). A is true but
incomplete; C is false; D mixes modalities incorrectly — the statement references
imaging reliance, not exam metrics.
Key words: incidentaloma, imaging correlation, specificity, overdiagnosis
8. A case history emphasizes a stepwise, relapsing-remitting motor weakness over
months. According to clinical reasoning taught in Chapter 1, which is the most
appropriate immediate differential direction?
A. Acute ischemic stroke.
B. Demyelinating disease such as multiple sclerosis.
C. Peripheral nerve transection.
D. Alzheimer’s disease.
Answer: B
Rationale: Relapsing-remitting focal neurologic deficits point toward
demyelinating processes (MS) among other inflammatory etiologies. Stroke is
typically sudden and static/stepwise deterioration may be vascular but relapsing-
remitting favors demyelination. Peripheral nerve transection presents with
persistent focal deficits; Alzheimer’s causes cognitive decline rather than focal
motor relapses.
Key words: relapsing-remitting, MS, demyelination, temporal profile
9. When a case presents with symmetrical proximal muscle weakness (e.g.,
shoulder girdle, hip flexors) over weeks, which diagnostic approach aligns with the
chapter’s emphasis on structured reasoning?
,A. Immediately order brain MRI to look for cortical lesions.
B. Consider myopathic processes (e.g., polymyositis), perform CK level and EMG,
then targeted imaging/biopsy as needed.
C. Assume psychogenic weakness and discharge.
D. Start high-dose steroids empirically without investigations.
Answer: B
Rationale: Symmetrical proximal weakness suggests myopathy. A structured
approach: labs (CK), EMG, then imaging or biopsy if indicated. Brain MRI (A) is
poorly targeted. C is inappropriate. D risks harm without diagnostic confirmation.
Key words: proximal weakness, myopathy, CK, EMG, structured approach
10. A neurologic examination in a case shows absent deep tendon reflexes and
marked weakness in a single limb following a shoulder dislocation. Using
localization principles, which site is most likely injured?
A. C5–C6 nerve roots or upper trunk of brachial plexus.
B. Left primary motor cortex.
C. Anterior horn cells diffusely.
D. Cerebellar hemisphere.
Answer: A
Rationale: Shoulder dislocation can injure upper brachial plexus (C5–C6) causing
focal limb weakness and hyporeflexia localized to those myotomes. B (cortex)
would give UMN signs (hyperreflexia, spasticity) not focal areflexia; C (anterior
horn cells) usually causes more widespread or progressive signs; D (cerebellum)
causes incoordination rather than focal weakness/areflexia.
Key words: brachial plexus, shoulder dislocation, C5–C6, hyporeflexia
11. A case’s history reveals orthostatic syncope and subtle memory complaints.
The neurologic exam is otherwise normal. Following the chapter’s guidance on
prioritizing problems, what is the most appropriate next step?
A. Pursue an extensive dementia workup immediately.
B. Focus the initial workup on autonomic causes (cardiac/orthostatic), correlate
with cognitive screening, and schedule targeted follow-up rather than broad,
immediate testing.
C. Order a whole-body PET scan.
D. Diagnose conversion disorder.
, Answer: B
Rationale: Prioritize the most pressing/likely cause of syncope
(autonomic/cardiac) while screening cognition (e.g., MoCA/MMSE). Broad or
invasive testing (C) is not appropriate first step; immediate dementia workup
without correlation is premature; diagnosing conversion disorder is unwarranted
without exclusion.
Key words: problem prioritization, orthostatic syncope, targeted workup,
cognitive screen
12. Which of the following cognitive biases is best guarded against by explicitly
writing your initial localization hypothesis before viewing imaging?
A. Anchoring bias.
B. Hindsight bias.
C. Confirmation bias.
D. Gambler’s fallacy.
Answer: C
Rationale: Writing a prior localization hypothesis aims to reduce confirmation
bias — the tendency to favor information that confirms a preexisting belief. It also
helps reduce anchoring (A) somewhat, but anchoring refers to fixation on early
information; here the key is preventing imaging confirmation from retrofitting an
exam-based hypothesis. Hindsight bias (B) and gambler’s fallacy (D) are less
relevant.
Key words: confirmation bias, hypothesis writing, cognitive error mitigation
13. In case presentations, “false localizing signs” (e.g., abducens palsy from raised
intracranial pressure) are important because they:
A. Always indicate a peripheral nerve lesion.
B. Can mislead localization if interpreted in isolation, so clinicians must integrate
temporal course, imaging, and other exam elements.
C. Prove that the neurologic exam is unreliable and should be ignored.
D. Show that cranial nerves never reflect intracranial processes.
Answer: B
Rationale: False localizing signs may mislead if taken alone; clinicians must
integrate all data and consider systemic processes (e.g., raised ICP causing sixth
Chapter 1: Introduction to Clinical Case Presentations
Chapter 2: Neuroanatomy Overview and Basic Definitions
Chapter 3: The Neurologic Exam as a Lesson in Neuroanatomy
Chapter 4: Introduction to Clinical Neuroradiology
Chapter 5: Brain and Environs: Cranium, Ventricles, and Meninges
Chapter 6: Corticospinal Tract and Other Motor Pathways
Chapter 7: Somatosensory Pathways
Chapter 8: Spinal Nerve Roots
Chapter 9: Major Plexuses and Peripheral Nerves
Chapter 10: Cerebral Hemispheres and Vascular Supply
Chapter 11: Visual System
Chapter 12: Brainstem I: Surface Anatomy and Cranial Nerves
Chapter 13: Brainstem II: Eye Movements and Pupillary Control
Chapter 14: Brainstem III: Internal Structures and Vascular Supply
Chapter 15: Cerebellum
Chapter 16: Basal Ganglia
Chapter 17: Pituitary and Hypothalamus
Chapter 18: Limbic System: Homeostasis, Olfaction, Memory and Emotion
Chapter 19: Higher-Order Cerebral Function
,Chapter 1 — Introduction to Clinical
Case Presentations
Below are 20 multiple-choice questions aligned with Chapter 1: Introduction to
Clinical Case Presentations. Each question has four choices (A–D), the answer
shown exactly as Answer: X, a deep rationale for the correct answer (including
why distractors are wrong), and a small set of key words.
1. What is the best initial cognitive step when you first read a neurologic case
history describing acute-onset unilateral weakness and aphasia?
A. Immediately request MRI brain with diffusion sequences.
B. Formulate a topographical localization hypothesis and a short differential based
on onset and distribution.
C. Start empiric anticoagulation for suspected cardioembolic stroke.
D. Order an EEG to exclude seizure as the cause.
Answer: B
Rationale: The correct first step is to form a localization hypothesis (which
cortical region/vascular territory) and a brief differential guided by timing and
symptom pattern. This frames subsequent choices (urgent CT/MRI, thrombolysis
decisions, labs). Option A is premature without targeted clinical localization and
urgency assessment (though imaging will be needed quickly). Option C is unsafe
without confirmation and stroke subtype assessment. Option D (EEG) is lower
priority for classic stroke presentation and would not be the immediate first step.
Key words: localization hypothesis, onset, differential, prioritization
2. In the book’s case-presentation format (history → exam → imaging →
diagnosis), which advantage is most reliably achieved by delaying imaging
interpretation until after a focused neurologic exam?
A. Minimizes time to definitive therapy.
B. Eliminates need for imaging in most cases.
C. Reduces cognitive bias by forcing independent clinical localization before
image confirmation.
D. Increases diagnostic sensitivity of CT scans.
,Answer: C
Rationale: Delaying interpretation of imaging until after a focused exam helps
reduce confirmation and availability bias — the clinician forms an independent
localization hypothesis and then tests it against imaging. A is false because
delaying imaging may increase time; B is false — imaging remains often
necessary; D is incorrect — imaging sensitivity is unaffected by interpretation
order.
Key words: cognitive bias, independent localization, confirmation bias
3. A patient presents with progressive numbness in a stocking-glove distribution
over months. According to clinical-reasoning principles introduced in Chapter 1,
which conclusion is most consistent to start your diagnostic thinking?
A. Localize the lesion to a single central nervous system focus.
B. Favor a peripheral polyneuropathy and generate systemic/metabolic
differentials.
C. Immediately suspect a brain tumor and schedule neurosurgery.
D. Attribute symptoms to a psychogenic cause because onset is slow.
Answer: B
Rationale: Stocking-glove distribution developing over months is classic for a
peripheral polyneuropathy (e.g., diabetic neuropathy, B12 deficiency). Thus
clinical reasoning should favor systemic/peripheral etiologies. A (single CNS
focus) is unlikely given symmetric distal distribution; C is not supported by
pattern; D is inappropriate without exclusion of organic causes.
Key words: stocking-glove, polyneuropathy, chronic, systemic causes
4. Which pattern of neurologic deficits most strongly suggests a brainstem lesion
rather than a cortical lesion?
A. Pure expressive aphasia without motor signs.
B. Contralateral hemiparesis and hemisensory loss with gaze preference toward the
lesion.
C. Ipsilateral cranial nerve deficits with contralateral long-tract motor or sensory
findings (i.e., “crossed” findings).
D. Progressive isolated memory loss over years.
Answer: C
Rationale: Crossed findings (ipsilateral cranial nerve involvement with
,contralateral limb deficits) are characteristic of brainstem lesions because cranial
nerve nuclei are ipsilateral while long tracts have already decussated or are on the
opposite side. A is cortical; B is more cortical/hemispheric; D suggests
neurodegenerative cortical disease.
Key words: crossed signs, brainstem, cranial nerves, long tracts
5. A 45-year-old with sudden severe headache and neck stiffness is described in a
case history. Following Chapter 1 principles, which immediate imaging modality
best matches the emergent clinical suspicion?
A. Noncontrast CT head to look for subarachnoid hemorrhage.
B. MRI brain with angiography as the first test.
C. Plain skull X-ray.
D. Cervical spine MRI.
Answer: A
Rationale: Sudden severe ("thunderclap") headache with meningeal signs raises
subarachnoid hemorrhage suspicion; noncontrast CT head is the fastest and most
sensitive in the acute window and is the appropriate emergent test. MRI/MRA can
be useful later but is less rapid. Skull X-ray and cervical MRI are irrelevant initial
choices.
Key words: thunderclap headache, SAH, noncontrast CT, emergent imaging
6. Which statement best reflects the concept of “localization of lesions”
emphasized in Chapter 1?
A. Symptoms always map directly and uniquely to single anatomic structures.
B. Localization synthesizes history and exam to identify the most likely anatomical
site(s), recognizing that some presentations may be multifocal or systemic.
C. Localization is obsolete because modern imaging always replaces the exam.
D. Localization only applies to peripheral nervous system disorders.
Answer: B
Rationale: Localization is an integrative skill—using history and exam to
hypothesize anatomical site(s)—while acknowledging limitations:
multifocal/systemic processes and false localizing signs exist. A is too rigid; C is
false — imaging complements but does not replace localization; D is wrong —
localization applies across CNS and PNS.
Key words: integration, hypothesis, multifocal, limits
,7. In the provided case format, what is the major risk of relying on imaging
findings alone without correlating the neurologic exam?
A. Increased healthcare costs only.
B. Overlooking incidental imaging abnormalities (incidentalomas) that do not
explain the clinical syndrome.
C. Complete elimination of diagnostic uncertainty.
D. Increased sensitivity but decreased specificity of the neurologic exam.
Answer: B
Rationale: Relying solely on imaging risks attributing symptoms to incidental
lesions unrelated to the patient’s presentation (incidentalomas). A is true but
incomplete; C is false; D mixes modalities incorrectly — the statement references
imaging reliance, not exam metrics.
Key words: incidentaloma, imaging correlation, specificity, overdiagnosis
8. A case history emphasizes a stepwise, relapsing-remitting motor weakness over
months. According to clinical reasoning taught in Chapter 1, which is the most
appropriate immediate differential direction?
A. Acute ischemic stroke.
B. Demyelinating disease such as multiple sclerosis.
C. Peripheral nerve transection.
D. Alzheimer’s disease.
Answer: B
Rationale: Relapsing-remitting focal neurologic deficits point toward
demyelinating processes (MS) among other inflammatory etiologies. Stroke is
typically sudden and static/stepwise deterioration may be vascular but relapsing-
remitting favors demyelination. Peripheral nerve transection presents with
persistent focal deficits; Alzheimer’s causes cognitive decline rather than focal
motor relapses.
Key words: relapsing-remitting, MS, demyelination, temporal profile
9. When a case presents with symmetrical proximal muscle weakness (e.g.,
shoulder girdle, hip flexors) over weeks, which diagnostic approach aligns with the
chapter’s emphasis on structured reasoning?
,A. Immediately order brain MRI to look for cortical lesions.
B. Consider myopathic processes (e.g., polymyositis), perform CK level and EMG,
then targeted imaging/biopsy as needed.
C. Assume psychogenic weakness and discharge.
D. Start high-dose steroids empirically without investigations.
Answer: B
Rationale: Symmetrical proximal weakness suggests myopathy. A structured
approach: labs (CK), EMG, then imaging or biopsy if indicated. Brain MRI (A) is
poorly targeted. C is inappropriate. D risks harm without diagnostic confirmation.
Key words: proximal weakness, myopathy, CK, EMG, structured approach
10. A neurologic examination in a case shows absent deep tendon reflexes and
marked weakness in a single limb following a shoulder dislocation. Using
localization principles, which site is most likely injured?
A. C5–C6 nerve roots or upper trunk of brachial plexus.
B. Left primary motor cortex.
C. Anterior horn cells diffusely.
D. Cerebellar hemisphere.
Answer: A
Rationale: Shoulder dislocation can injure upper brachial plexus (C5–C6) causing
focal limb weakness and hyporeflexia localized to those myotomes. B (cortex)
would give UMN signs (hyperreflexia, spasticity) not focal areflexia; C (anterior
horn cells) usually causes more widespread or progressive signs; D (cerebellum)
causes incoordination rather than focal weakness/areflexia.
Key words: brachial plexus, shoulder dislocation, C5–C6, hyporeflexia
11. A case’s history reveals orthostatic syncope and subtle memory complaints.
The neurologic exam is otherwise normal. Following the chapter’s guidance on
prioritizing problems, what is the most appropriate next step?
A. Pursue an extensive dementia workup immediately.
B. Focus the initial workup on autonomic causes (cardiac/orthostatic), correlate
with cognitive screening, and schedule targeted follow-up rather than broad,
immediate testing.
C. Order a whole-body PET scan.
D. Diagnose conversion disorder.
, Answer: B
Rationale: Prioritize the most pressing/likely cause of syncope
(autonomic/cardiac) while screening cognition (e.g., MoCA/MMSE). Broad or
invasive testing (C) is not appropriate first step; immediate dementia workup
without correlation is premature; diagnosing conversion disorder is unwarranted
without exclusion.
Key words: problem prioritization, orthostatic syncope, targeted workup,
cognitive screen
12. Which of the following cognitive biases is best guarded against by explicitly
writing your initial localization hypothesis before viewing imaging?
A. Anchoring bias.
B. Hindsight bias.
C. Confirmation bias.
D. Gambler’s fallacy.
Answer: C
Rationale: Writing a prior localization hypothesis aims to reduce confirmation
bias — the tendency to favor information that confirms a preexisting belief. It also
helps reduce anchoring (A) somewhat, but anchoring refers to fixation on early
information; here the key is preventing imaging confirmation from retrofitting an
exam-based hypothesis. Hindsight bias (B) and gambler’s fallacy (D) are less
relevant.
Key words: confirmation bias, hypothesis writing, cognitive error mitigation
13. In case presentations, “false localizing signs” (e.g., abducens palsy from raised
intracranial pressure) are important because they:
A. Always indicate a peripheral nerve lesion.
B. Can mislead localization if interpreted in isolation, so clinicians must integrate
temporal course, imaging, and other exam elements.
C. Prove that the neurologic exam is unreliable and should be ignored.
D. Show that cranial nerves never reflect intracranial processes.
Answer: B
Rationale: False localizing signs may mislead if taken alone; clinicians must
integrate all data and consider systemic processes (e.g., raised ICP causing sixth
