Presence of intrinsic high T1 signal in the basal ganglia raised the possibility of underlying acquired hepatocerebral degeneration with superimposed hepatic encephalopathy accounting for T2 signal abnormality and clinical presentation. At the time no history of liver disease was present however. 

Recent blood work revealed elevated ammonia levels at 100 umol/L (normal <55 umol/L), and deranged liver function tests. 

In the setting of suspected hepatic encephalopathy, the patient went on to have an ultrasound which demonstrated imaging findings of cirrhosis without ultrasound evidence of portal hypertension. Both ARFI (shear wave elastography) measurement sets are in the cirrhotic range. 

The patient was managed medically and mental state returned to normal.