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We present the case of a 53-year-old female presenting with bilateral hand paraesthesia on waking with progression to flaccid quadriplegia within 24 hours of onset complicated by acute respiratory failure.MR imaging of the spinal cord demonstrated features of T2 hyperintensity between levels of C3-C6.A preliminary diagnosis of longitudinally extensive transverse myelitis was made by the general physicians. Cerebrospinal fluid (CSF) analysis showed a mildly raised CSF protein. Our patient received intravenous methylprednisolone based upon the suspicion of inflammatory aetiology.Review of the clinical history by a Neurologist prompted exploration for acute ischaemic myelopathy. This was confirmed with dedicated diffusion weighted MR imaging of the spinal cord.CT angiography ruled out cervical artery dissection.Extensive investigation for thromboembolic, infective, inflammatory and neoplastic disorders returned negative.Our patient made a slow, but gradual neurological recovery.Our case highlights the importance of clinical history and examination when formulating a neurological diagnosis. Specialist neuroimaging sequences play a crucial role and in our experience can be readily obtained within a district general hospital setting with interpretative support from specialist neuroradiologists.Accurate diagnosis in this case avoided the initiation of potentially futile treatments with early multidisciplinary stroke input crucial in maximising neurological recovery.sabaarshadali5@gmail.com