What is the workup for a 58-year-old female with a history of seizure disorder presenting with unilateral hand swelling?

From the Guidelines

The workup for a 58-year-old female with a history of seizure disorder presenting with unilateral hand swelling should start with a comprehensive medical history and physical examination (H&P), as well as laboratory tests including CBC with platelet count, PT, aPTT, fibrinogen, and liver and kidney function tests 1.

Initial Evaluation

• The patient's symptoms of unilateral hand swelling could be indicative of deep vein thrombosis (DVT), and a high level of clinical suspicion is warranted 1.
• Venous ultrasound is the preferred initial imaging method for diagnosing DVT, and can detect asymptomatic DVT in a significant proportion of patients 1.

Further Imaging

• If the initial ultrasound results are negative or indeterminate, and there is still a high clinical suspicion of DVT, repeat venous ultrasound, contrast-enhanced CT venography (CTV), or magnetic resonance venogram (MRV) with contrast may be considered 1.
• CTV has been reported to be as accurate as ultrasound in diagnosing femoropopliteal DVT, and may be superior in detecting thrombus in large pelvis veins and the inferior vena cava (IVC) 1.
• MRV with contrast allows enhanced venous signal and has been reported to have higher sensitivity for proximal DVT than distal DVT, with equivalent sensitivity and specificity to ultrasound for diagnosing DVT 1.

Differential Diagnosis

• Other potential causes of unilateral hand swelling, such as central venous stenosis or venous hypertension, should also be considered, particularly if the patient has a history of vascular access or other relevant medical history 1.
• A thorough evaluation of the patient's symptoms, medical history, and laboratory results is necessary to determine the underlying cause of the unilateral hand swelling.

From the Research

Diagnostic Considerations

The workup for a 58-year-old female with a history of seizure disorder presenting with unilateral hand swelling should consider the following:

• The possibility of compartment syndrome, as seen in a case of hand compartment syndrome secondary to an epileptic seizure 2
• The potential for underlying conditions such as lipedema, a disease characterized by subcutaneous adipose tissue deposition, which can cause unilateral edema 3
• The risk of cerebral tumour in patients with unilateral motor seizures, particularly if they begin after the age of 20 years 4

Imaging and Diagnostic Tests

• Magnetic resonance imaging (MRI) may be useful in evaluating unilateral brain edema related to focal status epilepticus 5
• Lower extremity venous duplex ultrasound may be used to reveal the underlying etiology of unilateral edema, which is frequently of vascular origin 3
• A thorough physical examination and patient history are essential in determining the cause of unilateral hand swelling

Seizure Disorder Considerations

• Unilateral motor epileptic seizures can be a manifestation of partial (focal, localisation related) epilepsy or generalised onset epilepsy 4
• Focal status epilepticus may cause unilateral brain edema, and cytotoxic edema probably plays an important role in the pathophysiology of brain injury 5