CASE PRESENTATION: A 48 year old male with a past medical history of mild cerebral palsy (CP) presented with slurring of speech and confusion. A Head CT revealed a left cerebellar ischemic stroke in evolution confirmed on MRI along with small brainstem infarcts. Emergent angiography revealed thrombosis of the left vertebral artery with excellent collateral circulation. Clot extraction was then judged to represent more risk than benefit. The patient was admitted to the ICU where systolic blood pressure was maintained between 140-180 mm Hg and 3% hypertonic saline was administered. He was clinically stable for the first two days of admission, however, aspiration remained a prominent problem ultimately resulting in pneumonia and profound septic shock. The creatinine rose from 1.3 to 7.2 in 2 days with profound acidosis and continuous renal replacement therapy was initiated. At this time his serum sodium was recorded at 165 mmol/L.