CASE PRESENTATION: Patient is a 49 yo male with past medical history significant for HTN, DM, CHF, presenting with two days of dysarthria and bilateral lower extremity weakness resulting in a fall on day of admission. On physical exam, cranial nerves two through twelve were intact, cerebellar signs negative, sensory was intact bilaterally upper and lower extremities. Patient was admitted for stroke work up with an NIHSS of 5. CT brain and MRI showed no acute pathology. Over the next 4 days, patient developed worsening flaccid quadraplegia with bulbar symptoms. Repeat MRI on day 5 of admission showed bilateral basilar pontine infarcts on diffusion weighted imaging (DWI) not previously seen. NIHSS progressed to 12 and on day five, patient required intubation for airway protection. Exam at this time included quadraplegia and complete anarthria, with preservation of eye movement. After an extended period in the critical care unit, patient was discharged to a rehabilitation center.