Background: Lateral medullary (Wallenberg) syndrome is the most common stroke syndrome related to vertebral artery disease. The hallmark of this syndrome is crossed sensory findings affecting the contralateral trunk and extremities and the ipsilateral side of the face. This is in addition to dysarthria, dysphagia, vertigo, and Horner's syndrome. Unilateral vocal cord dysfunction is frequently seen, but bilateral vocal cord paralysis is an extremely rare and potentially life threatening complication. Case Presentation: We present the case of a 75 year-old man who presented with the diagnosis of acute lateral medullary (Wallenberg) syndrome, and experienced bilateral vocal cord paresis leading to acute airway obstruction. Conclusion: We report a rare manifestation of acute ischemic stroke: bilateral vocal cord paresis. We propose an underlying neuroanatomical mechanism for bilateral vocal cord involvement.