30-year-old female with past medical history of hypertension and migraines presented with bilateral fronto-occipital headache, slurred speech and left arm numbness for one day. Vitals signs were remarkable for blood pressure of 225/117. MRI brain showed diffusion restriction of the midbrain and pons with contrast enhancement and significant vasogenic edema. Cerebral angiogram and lumbar puncture were unremarkable. Over the next two days patient had worsening left sided weakness in addition to new dysmetria in the left upper extremity. Repeat MRI brain showed expansion of pontine lesion with involvement of inferior cerebellar peduncle and the upper medulla along-with hemorrhage in the pons. Patient was empirically started on antibiotics to cover for listeria, HSV and nocardia. Cervical lumbar puncture was performed which was negative for autoimmune, neoplastic and infectious etiology. Patient also underwent plasma exchange for 3 days with mild improvement. Patient refractory hypertension was controlled with four anti-hypertensive medications after which there was arrest in patient decline. Repeat MRI brain showed stable changes in the midbrain, pons, medulla and the cerebellar peduncles. Antibiotics were discontinued and patient was discharged to acute rehabilitation facility with mRS of 4.