Status epilepticus is defined as one seizure persisting for greater than 5 minutes, or two seizures within a 5-minute period without interval return to baseline. This condition is characterized by intractable seizure and represents a true medical emergency, as it poses a severe threat of anoxic brain injury that increases with duration of seizure. Status epilepticus has widely varied causes, including but not limited to hypoglycemia, electrolyte abnormalities, substance withdrawal, medications/toxins, new-onset primary seizure disorders, malignancy, and trauma. Following the classic primary survey, management should focus on cessation of seizure activity through administration of benzodiazepines, with progression to phenytoin/fosphenytoin and even barbiturates should seizures remain refractory. Airway protection should be actively maintained given the often-high doses of these medications. Work-up should include basic laboratory panels, including CBC, BMP, LFTs, coags, UA, serum tox, ABG, and ECG; imaging should include CXR and CT head. A thorough history should be obtained from patient/family/bystanders if possible following stabilization, and neurology consult should be considered.

This chapter presents a case of a 47-year-old male with confusion secondary to hyponatremia, caused by beer potomania (excessive beer consumption). The case highlights the approach to a patient with an altered mental status, seizures, and severe hyponatremia. The approach to diagnostic testing, stabilization, and interventions to prevent progression and deterioration to a comatose state are described.

Generalized seizures that occur in children between 6 months and 5 years of age during a febrile illness and last less than 15 minutes are known as simple febrile seizures. Children may experience a brief post-ictal period but should return to baseline fairly quickly. Children with simple febrile seizures should be given antipyretics and a careful history and physical should be performed. If a source of the fever is identified, it should be treated. Most often, children do not require blood work or a lumbar puncture in the work-up of a simple febrile seizure. If the child has returned to baseline and is well-appearing, they may be discharged home with follow-up with their primary care physician. Complex febrile seizures, in contrast, may last longer than 15 minutes, may occur several times in a short period of time, or may be focal. A more thorough work-up is often required for complex febrile seizures.

Seizure can have multiple precipitating factors. A broad initial differential diagnosis is critical to rapidly identify the underlying etiology of seizure, including hypoglycemia, hypoxemia, intracranial hemorrhage or infection, electrolyte abnormalities, withdrawal, or underlying epilepsy. One specific cause of seizure is pregnancy in the third trimester, termed eclampsia. Risk factors for eclampsia include young or old age, primigravida or nulliparity, multifetal gestations, obesity, chronic hypertension, kidney disease, and diabetes. The management of eclampsia includes magnesium sulfate and blood pressure control as needed. Magnesium sulfate can be given as a 4−6 g IV bolus, followed by a continuous infusion of 2 g per hour, with monitoring for magnesium toxicity as evidenced by loss of deep tendon reflexes, hypotension, or respiratory depression. Magnesium toxicity can be treated with calcium gluconate. Elevated blood pressure refractory to magnesium administration should be treated with antihypertensives, including intravenous labetalol or hydralazine, or oral nifedipine. Blood pressure targets are a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure of less than 110 mmHg. Emergent obstetrics consultation is required, as delivery of the fetus is the only definitive treatment.

A 48-year-old male with a known history of alcohol abuse is brought in by EMS for altered mental status. Upon arrival to the ED, he is atraumatic, hypertensive, tachycardic, confused, agitated, uncooperative, and diaphoretic. Fingerstick is within normal limits. He is sedated to expedite work-up and for patient and staff safety. A “coma cocktail” is administered without adequate response. The patient subsequently develops a grand mal seizure responsive to benzodiazepines. Alcohol level is 56 and the rest of the bloodwork is unremarkable. CT head without contrast is negative for acute intracranial hemorrhage. The patient is admitted to the ICU for alcohol withdrawal seizures.

1. Pharmacologic management of active seizure in cancer patients starts with benzodiazepines, followed by levetiracetam or lacosamide load. For refractory seizures, intubate and start a benzodiazepine infusion.

2. Tailor a differential diagnosis. Determine whether the seizure was focal or generalized. Obtain a history of their treatments, medications and recent changes, preceding symptoms, and determine if there are residual symptoms or deficits.

3. New seizures in any cancer patient should prompt imaging to evaluate for structural lesion, first with non-contrast CT head followed by gadolinium-enhanced MRI. Focal seizures suggest focal causation.

4. Continuous video EEG is preferred, as shorter EEG may fail to capture non-convulsive status epilepticus (NCSE).

5. Metabolic derangements can present with seizures and is common in patients with oncologic processes. Therefore, a high degree of suspicion and low threshold for repletion of electrolytes and correction of acid-base abnormality is imperative.

Chapter 2.7 explores anticonvulsant drugs. This includes a segment on benzodiazepines commonly used for sedation and anaesthesia, their mechanism of action, uses, side effects and actions in overdose. We then discuss specific antiepileptic agents in detail and the management of status epilepticus.

Introduction to ECT

Hypertension disorders of pregnancy are a clinical spectrum that includes gestational hypertension, preeclampsia, and eclampsia. Hypertensive disorders are a common cause of significant maternal and fetal morbidity and mortality. Therefore, it is important for women’s health clinicians to be knowledgeable of the diagnostic criteria and management guidelines. A 25-year-old gravida 3 para 0 at 35 weeks’ gestation presents with a blood pressure of 165/95, proteinuria, and develops seizures. Based on her clinical presentation, physical examination, and laboratory findings, a diagnosis of eclampsia was made. The patient was promptly stabilized, treated with magnesium sulfate for seizure prophylaxis, received antihypertensive treatment, and delivered in a timely manner. The case highlights the recommended maternal evaluation, fetal surveillance, timing of delivery, and treatment for hypertension disorders of pregnancy.

Epilepsy is one of the most common neurological disorders, affecting people of all ages. This chapter focusses on what has been learnt about the microRNA system in this important disease. Starting with an overview of epilepsy, it addresses what causes seizures to occur and some of the underlying mechanisms, including gene mutations and brain injuries. It explores how and which microRNAs drive complex gene changes that underpin but also oppose the enduring hyperexcitability of the epileptic brain. This includes by regulating amounts of neurotransmitter receptors, structural components of synapses, metabolic processes and inflammation. It also covers some of the earliest studies linking microRNAs to epilepsy as well as recent large-scale efforts to map every microRNA and its target in the epileptic brain. Finally, it highlights ways to model epilepsies and use of experimental tools such as antisense oligonucleotides to understand the contributions of individual microRNAs. Collectively, these studies reveal how microRNAs contribute to the molecular landscape that underlies this disease and offer the exciting possibility of targeting microRNAs to treat genetic and acquired epilepsies.

Shortly after microRNAs were discovered in humans they were found to be present in blood samples. This led to another branch of microRNA research with the potential to transform medicine, answering the question healthcare professionals ask every day. What’s wrong with my patient? This chapter introduces circulating microRNAs as biomarkers and their emergence as potential diagnostic tools. Core arguments in their favour as indicators of health and disease include tissue specificity, their known locations in the body enabling doctors to zero in on where a problem lies. It looks at what shelters microRNAs as they circulate in the bloodstream and the disruptive thinking that has interpreted such findings as evidence that extracellular microRNAs are conveyors of information between distant tissues in the body. It moves to efforts to probe ever-smaller volumes of biofluids to find the least-invasive source of microRNA biomarkers and the diseases for which microRNA-based diagnostic tests already exist or may emerge in the future. Finally, it looks at developments in RNA detection technology that might allow point-of-care testing and perhaps microRNA-based health monitoring at home.

This chapter focuses on several of the most common actionable EEG abnormalities. This includes defining and describing epileptiform discharges, which are abnormal EEG waves that serve as markers of increased seizure risk. This also includes seizures themselves, and their characteristics and electrographic criteria. Prolonged and repetitive seizures known as status epilepticus are described, including their specific electrographic characteristics and criteria. The treatment resistant form of status epilepticus known as refractory status epilepticus is also described. Finally, the chapter describes a high risk electrographic phenomenon known as brief potentially ictal rhythmic discharges (BIRDs).

This chapter focuses on quantitative EEG processing, also known as EEG trend analysis. These types of algorithms process raw EEG data in a quantitative way, and display the data in more compressed forms that may be easier for the amateur EEG reader to interpret. Specific QEEG algorithms described in this chapter include amplitude integrated EEG, FFT spectrogram, rhythmicity spectrogram, asymmetry indices, and seizure detectors. Specific roles for QEEG covered include seizure detection and detection of focal cerebral ischemia.

This chapter examines a key aspect of the worldwide sanctions response: sanctioning individuals personally, including wealthy oligarchs holding vast, often-hidden wealth. This chapter explores how and why certain individuals were sanctioned, like Putin’s daughters and prominent Russian government and business figures. Lesser-known sanctioned figures are also discussed. It also discusses the difficulties of linking assets to sanctioned individuals once wealth is laundered and converted into certain types of assets. The chapter discusses measures taken by various jurisdictions to improve the effectiveness of sanctions by promoting financial transparency.

This chapter reviews how the recent sanctions have been enforced, both by domestic authorities and through multilateral cooperation. chapter also examines strategies taken by would-be sanctions evaders to conceal their attempts to circumvent the broad sanctions. Enforcement plays a key role in the ability of the sanctioning jurisdictions to effectively implement their sanctions and incentivize change in the behavior of the target or by parties indirectly affected by the sanctions.