7
Table 2. ICANS Recommendations
Workup/Evaluation and supportive care recommendations (all grades):
• Routine neurological evaluation including the Immune Effector Cell-Associated
Encephalopathy (ICE) score for cognitive assessment and assessment of motor
weakness conducted at least two times a day.
• Continually reassess for improvement or deterioration and escalate/deescalate
treatment and monitoring accordingly.
• Serial monitoring of laboratory tests including CRP, ferritin, CBC, CMP, fibrinogen,
PT/PTT.
• Consider seizure prophylaxis for CAR T-cell products known to be associated with
ICANS or in patients at higher risk of seizure, such as those with prior seizure history,
CNS disease, concerning EEG findings, or neoplastic brain lesions.
• Initiate neurolog y consultation in patients with signs of neurotoxicity.
• Aspiration precautions, elevated head of bed.
• Neuroimaging of the brain (MRI with and without contrast or CT if MRI is not
available/feasible) for ≥G2 neurotoxicity. For persistent Grade ≥3 neurotoxicity,
consider repeat neuroimaging (MRI or CT) every 2–3 days.
• Lumbar puncture for ≥G3 neurotoxicity and may consider for G2.
• EEG evaluation for unexplained altered mental status to assess seizure activity or for
≥G2 neurotoxicity.
• Monitor and correct severe hyponatremia.
Grading
¥
(based on ASTCT
consensus grading ) Management
G1:
ICE score:* 7–9 with no
depressed level of consciousness
No Concurrent CRS
• Offer supportive care with IV hydration and
aspiration precautions.
With Concurrent CRS
• Administer tocilizumab 8 mg/kg IV over 1
hour (not to exceed 800 mg/dose). Repeat
every 8 hours as needed. Limit to a maximum
of 3 doses in a 24-hour period; maximum total
of 4 doses. Caution with repeated tocilizumab
doses in patients with ICANS. Consider adding
corticosteroids to tocilizumab past the first dose.
