This chapter uses a case-based approach to discuss the electrographic patterns associated with focal cortical lesions in critically ill patients. Focal amplitude attenuation and/or slowing may suggest an underlying physiological dysfunction or a structural lesion. Additionally, epileptiform abnormalities such as sharp waves within the region may suggest increased seizure risk. A focal pattern of higher amplitudes, sharper morphologies, and faster activities is characteristic of breach effect from a craniotomy. Lateralized rhythmic delta activity (LRDA) is a pattern of rhythmic focal slowing that is associated with increased seizure risk. Epilepsia partialis continua (EPC) is an unusual form of focal motor status epilepticus that is often refractory to antiseizure medications. This pattern may be seen in a rare form of focal epilepsy called Rasmussen syndrome among other causes.

Status epilepticus (SE) is a neurological emergency defined as a continuous seizure or cluster of seizures lasting longer than 30 minutes. Because of increased mortality risk, SE is practically defined at 5 minutes. Clinically, SE can be separated into convulsive SE (CSE) or nonconvulsive SE (NCSE). For both diagnoses, the initial treatment of choice is a benzodiazepine, most commonly lorazepam 4 mg IV. Midazolam and diazepam (to a lesser extent) are also appropriate. If the status epilepticus continues, loading doses of fosphenytoin (20 mg/kg), levetiracetam (60 mg/kg), or valproate (40 mg/kg) are the next step in management. Continuation of SE past this point is considered refractory. For CSE, patients are almost always intubated and managed with IV anesthesia. For NCSE, intubation is often not needed at this point, with additional ASMs used instead to sidestep the risk associated with intubation and IV anesthesia. A key factor in guiding SE management is identifying the etiology (i.e., antibiotics for meningitis).Lastly, post cardiac arrest is briefly discussed as it is unfortunately commonly encountered.

First-time seizures are a common part of neurology practice. Making an accurate and specific diagnosis is achievable by taking an excellent history. Clinicians should keep in mind that seizures are only part of the differential in a patient with a first-time event, with other diagnoses like syncope common as well. This history should focus on what the seizure feels like to the patient and looks like to observers. Two classification systems, the seizure semiology and International League Against Epilepsy (ILAE), exist to make communicating complex information easier. Key semiology history includes the presence or absence of auras, altered awareness, or convulsions. In addition to history, laboratory, EEG, and imaging data can inform to the specific patient diagnosis. If you determine that the patient has had a first-time seizure without a clear epilepsy diagnosis, you can tell them seizure that the recurrence risk is 40%. If you determine the patient has epilepsy, you can tell them that 50% of people are seizure-free with the first medication used. Patients should be reassured that they can live normal lives with most jobs being obtainable and family life being a possibility if the patient so chooses.

A seizure is defined as abnormally coordinated electrical activity that is clinically noted as abnormal sensations, movements, or behaviors. Epilepsy is defined as the tendency to have seizures, practically as two unprovoked seizures at least 24 hours apart or one seizure with a 60% chance of additional seizures. The two overall epilepsy types are generalized and focal. Focal epilepsy most commonly indicates a focal brain injury like traumatic brain injury or tumor. In contrast, generalized epilepsy is due to a genetic etiology, not necessarily inherited. An epilepsy diagnosis is clinically made and can be supported by typical EEG and MRI findings. Nearly 4% of people develop epilepsy, with the largest peak during later years and the second peak during childhood. Nearly 70% of people are seizure-free after five years, whether via control with medications or, less commonly, the epilepsy itself remits. Life expectancy for epilepsy patients is lower. A key contributor to epilepsy mortality is sudden unexpected death in epilepsy (SUDEP). Uncontrolled generalized tonic clonic seizures are a key risk factor for SUDEP.

In this chapter, I first consider Alasdair MacIntyre’s neo-Aristotelian notion of “practices.” For MacIntyre, practices refer to special forms of human activity that harbor what he calls internal goods, goods to which practitioners progressively gain access as they acquire more experience. Part of what it means to enact a leisurely state of mind is to become attentive to the internal goods of our practical engagements. At the same time, the activities in which we can cultivate and enact leisure should not only be thought of as “practices,” in the MacIntyrean sense. Attending only to such practices would narrow the range of human engagement in which leisure can be experienced. More provocative is the philosopher Albert Borgmann’s  notion of a focal practice, which resonates with MacIntyre’s account, but includes a broader range of activities that count as worthwhile practices. While Borgmann’s account of focal practices covers what MacIntyre has in mind, it also includes simple activities such as cooking, walking, and reading. Borgmann shows that even, and especially in such engagements, we can experience and further cultivate leisure. Drawing from both MacIntyre’s and Borgmann’s insights, I sketch out three tangible ways to cultivate leisure.

Seizures (epileptic) are manifestations of transient abnormal excessive or synchronized cerebral neuronal activity. Seizures may be provoked (acute conditions) or unprovoked (epilepsy). Seizures are classified as focal or generalized onset based on consistent clinical observation, EEG and imaging findings. Focal onset seizures originate from a single hemisphere while generalized seizures originate from bilateral hemispheres. Focal seizures may be further classified based on impairment of awareness (anytime during seizure) and motor or non-motor activity (at the very onset). Focal seizures without impaired awareness may not have surface EEG abnormalities. Focal seizures may secondarily generalize, these are now called focal to bilateral tonic clonic seizures. Generalized seizures are associated with impaired awareness, hence only motor or non-motor activity at onset is used to classify them. Common generalized motor seizures include generalized tonic clonic seizures (GTCs), tonic, atonic, myoclonic, myoclonic-atonic and epileptic spasms. Common generalized non-motor seizures include typical and atypical absences, myoclonic absences and absences with eyelid myoclonia.