BACKGROUND Isolated spinal artery subarachnoid hemorrhage is a rare occurrence in the general population, but occurs more commonly as one of many neurologic sequela of systemic lupus erythematosus (SLE). The etiology of a neurologic deficit in an SLE patient is often multifactorial. Comorbid conditions, such as antiphospholipid antibody syndrome, predispose to stroke. Other diagnoses, including transverse myelitis, may also be attributed to local inflammation. CASE REPORT A 37-year-old woman with SLE and antiphospholipid antibody syndrome experienced severe back pain followed by sudden paralysis and sensory loss below the T2 level. She remained alert and oriented on examination, with neurologic exam positive for diminished strength in the arms and with total loss of sensation and strength in the legs. Diagnostic workup was limited due to a contrast allergy and severe lupus nephritis; however, initial imaging showed increased cervical-thoracic spinal cord signal and concern for acute blood in the subarachnoid space. No neurosurgical intervention occurred, and the patient was treated with high-dose steroids and plasmapheresis for a possible transverse myelitis and non-aneurysmal subarachnoid hemorrhage. The patient received further neurologic and rheumatologic workup and remained neurologically stable, with improvement in proximal arm strength on physical exam. CONCLUSIONS We highlight the diagnostic challenges in treating a patient with SLE with acute paralysis and sensory loss. In this case, aggressive early treatment of the patient's myelitis and myelopathy were successful in leading to mild neurological improvement.