A multi-agent approach to neurological clinical reasoning

Large language models (LLMs) have demonstrated impressive capabilities in medical domains, yet their ability to handle the specialized reasoning patterns required in clinical neurology warrants systematic evaluation. Neurological assessment presents distinctive challenges that combine anatomical localization, temporal pattern recognition, and nuanced symptom interpretation-cognitive processes that are specifically tested in board certification examinations. We developed a comprehensive benchmark comprising 305 questions from Israeli Board Certification Exams in Neurology and classified each along three dimensions of complexity: factual knowledge depth, clinical concept integration, and reasoning complexity. We evaluated ten LLMs of varying architectures and specializations using this benchmark, testing base models, retrieval-augmented generation (RAG) enhancement, and a novel multi-agent system. Our analysis revealed significant performance variation across models and methodologies. The OpenAI-o1 model achieved the highest base performance (90.9% accuracy), while specialized medical models performed surprisingly poorly (52.9% for Meditron-70B). RAG enhancement provided variable benefits across models; substantial improvements for mid-tier models like GPT-4o (80.5% to 87.3%) and smaller models, but limited effectiveness on the highest complexity questions regardless of model size. In contrast, our multi-agent framework-which decomposes neurological reasoning into specialized cognitive functions including question analysis, knowledge retrieval, answer synthesis, and validation-achieved dramatic improvements, especially for mid-range models. The LLaMA 3.3-70B-based agentic system reached 89.2% accuracy compared to 69.5% for its base model, with particularly substantial gains on level 3 complexity questions across all dimensions. External validation on MedQA revealed dataset-specific RAG effects: while RAG improved board certification performance, it showed minimal benefit on MedQA questions (LLaMA 3.3-70B: + 1.4% vs + 3.9% on board exams), reflecting alignment between our specialized neurology textbook and board examination content rather than the broader medical knowledge required for MedQA. Most notably, the multi-agent approach transformed inconsistent subspecialty performance into remarkably uniform excellence, effectively addressing the neurological reasoning challenges that persisted even with RAG enhancement. We further validated our approach using an independent dataset comprising 155 neurological cases extracted from MedQA. The results confirm that structured multi-agent approaches designed to emulate specialized cognitive processes significantly enhance complex medical reasoning offering promising directions for AI assistance in challenging clinical contexts.