A 53-year-old right-handed man with diabetes, hypertension, a history of cigarette smoking, and previous right middle cerebral artery (MCA) infarct with residual left hemiparesis had
sudden onset of slurred speech and right-sided weakness. Due to inability handling secretions, he had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement at the local hospital. Due to clinical deterioration, he was transferred for further evaluation.

Our patient had multiple vascular risk factors. He experienced acute onset of right-sided weakness and slurred speech and found to be markedly dysarthric with a decreased gag reflex and severely impaired swallowing. As he became unable to handle his own secretions, he had a tracheostomy and placement of a PEG tube. He was then transferred to our center for further evaluation and management.