9
Table 2. ICANS Recommendations
G4:
ICE score:* 0 (patient is
unarousable and unable to
perform ICE)
And/or
Stupor or coma
And/or
Life-threatening prolonged
seizure (>5 min) or repetitive
clinical or electrical seizures
without return to baseline in
between
And/or
Diffuse cerebral edema on
neuroimaging, decerebrate
or decorticate posturing, or
papilledema, cranial nerve VI
palsy, or Cushing's triad
All G4 patients:
• Admit patient to ICU if not already receiving
ICU care. Consider mechanical ventilation for
airway protection.
No Concurrent CRS
• Administer high-dose methylprednisolone IV
1,000 mg 1–2 times per day for 3 days.
• If not improving, consider 1,000 mg of
methylprednisolone 2–3 times per day or
alternate therapy.****
• Continue corticosteroids until improvement to
Grade 1, then taper as clinically appropriate.***
• Status epilepticus to be treated as per
institutional guidelines.
With Concurrent CRS
• Administer tocilizumab as per Grade 1 in
addition to methylprednisolone 1,000 mg
intravenously 1–2 times per day for 3 days.
• If not improving, consider 1,000 mg of
methylprednisolone intravenously 2–3 times a
day or alternate therapy.****
• Continue corticosteroids until improvement to
Grade 1, then taper as clinically appropriate.***
Footnotes:
• Other signs and symptoms such as headache, tremor, myoclonus, asterixis,
parkinsonism, and hallucinations may occur and could be attributable to immune
effector-cell engaging therapies. Although they are not included in the grading scale,
careful attention and directed therapy may be warranted.
• A patient with an ICE score of 0 may be classified as Grade 3 ICANS if awake with
global aphasia, but a patient with an ICE score of 0 may be classified as Grade 4
ICANS if unarousable.
• Decreased level of consciousness should be attributable to no other cause (e.g., no
sedating medication).
• In cases of ICANS with concurrent CRS, tocilizumab use is directed at the
concurrent CRS as tocilizumab has not been shown to mitigate neurologic toxicity.
• Because of the possibility that tocilizumab may worsen ICANS, the management of
ICANS may take precedence over the management of low-grade CRS when the 2
occur simultaneously. For example, a patient with Grade 2 ICANS and fever alone
(Grade 1 CRS) should be given steroids.
(cont'd)
