Immune effector cell-associated neurotoxicity syndrome

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Background

Clinical Manifestations

  • Encephalopathy, delirium, confusion, disorientation
  • Seizures
  • Aphasia or dysphasia
  • Tremor, ataxia
  • Dyscalculia
  • Headache

ASTCT ICANS Grading1

Domain Grade 1 Grade 2 Grade 3 Grade 4
ICE score 7-9 3-6 0-2 Unarousable
Level of consciousness Awakens spontaneously Awakens to voice Awakens to tactile stimulus Unarousable, stupor, coma, or requires vigorous or repetitive tactile stimuli
Seizure Any that resolves rapidly, or nonconvulsive seizure on EEG that resolves with intervention Life-threatening seizure >5 min or status epilepticus
Motor findings Deep focal motor weakness, such as hemiparesis or paraparesis
ICP/cerebral edema Focal or local edema on neuroimaging Diffuse cerebral edema on neuroimaging; decerebrate or decorticate posturing;cranial nerve VI palsy; papilledema; or Cushing triad

ICE Assessment Tool

Domain Description Points
Orientation orientation to year, month, city, and hospital 4
Naming ability to name 3 objects (e.g. point to clock, pen, button) 3
Following commands ability to follow simple commands (e.g. "Show me 2 fingers", "Close you eyes and stick out your tongue" 1
Writing ability to write a standard sentence (e.g. "Our national bird is the bald eagle") 1
Attention ability to count backwards from 100 by 10 1

Management

  • High-dose steroids, depending on grading

References

  1. ^  Daniel W. Lee, Bianca D. Santomasso, Frederick L. Locke, Armin Ghobadi, Cameron J. Turtle, Jennifer N. Brudno, Marcela V. Maus, Jae H. Park, Elena Mead, Steven Pavletic, William Y. Go, Lamis Eldjerou, Rebecca A. Gardner, Noelle Frey, Kevin J. Curran, Karl Peggs, Marcelo Pasquini, John F. DiPersio, Marcel R.M. van den Brink, Krishna V. Komanduri, Stephan A. Grupp, Sattva S. Neelapu. ASTCT Consensus Grading for Cytokine Release Syndrome and Neurologic Toxicity Associated with Immune Effector Cells. Biology of Blood and Marrow Transplantation. 2019;25(4):625-638. doi:10.1016/j.bbmt.2018.12.758.