AxD is a rare group of degenerative leukodystrophies that has traditionally been categorized into three distinct diagnoses based on age at symptom onset: infantile (birth to 2 years), juvenile (2 – 14 years), and adult (> 14 years) [4]. Infantile AxD is fatal, characterized by macrocephaly, psychomotor regression, spasticity, ataxia and seizures [4]. Conversely, adult onset AxD is often protracted, presenting with vague and progressive muscular and bulbar symptoms. Severe pyramidal involvement in type II AxD can result in paresis and dysarthria suggestive of an ischemic neurologic event, as seen in this case, while bulbar involvement may contribute to aspiration pneumonia presenting with fever and respiratory failure [8]. The clinical differential diagnosis for our patient included, but was not limited to, hereditary spastic paraplegia and spinocerebellar ataxia. MRI findings are helpful in this regard, as patients with type II disease commonly have atrophy limited to the brainstem and upper cervical spinal cord that worsen with disease duration [7]. Sequence abnormalities may range from subtle T2 high-signal-intensity changes in the upper corticospinal tract to extensive confluent white matter changes in a frontoparietal distribution, along the corticospinal tract, as well as in the medulla and upper and middle cerebellar peduncles.