Exclusion and/or prophylactic treatment of differential:
- Consider neuroimaging to exclude space occupying lesion, stroke or other ICANS mimic
- Consider lumbar puncture and antimicrobial coverage for central nervous system infection
- Medications review to exclude iatrogenic neurotoxicity
- Electroencephalogram can show focal or global slowing, generalised rhythmic delta activity, or seizure patterns such as bilateral periodic discharges and non-convulsive status epilepticus
Generalised supportive measures:
- Close monitoring including neurological status; ICANS can deteriorate rapidly
- Neuroprotective measures including avoidance of fever, glucose control, ensuring adequate cerebral perfusion pressure, and control of pO2 and pCO2
- In cerebral oedema, hyperosmolar therapy may be of benefit
Specific management:
- Severity can be graded according to Immune Effector Cell Encephalopathy (ICE) score into four grades, which determines specific management strategies
- ICANS grade 1 is least severe with an ICE score of 7-9, and requires supportive management only
- ICANS grade 2 and above may require steroid treatment, and in treatment resistant cases, high dose cyclophosphamide, anakinra or siltuximab could be considered
- In concurrent acute CRS the benefits of immunosuppression must be finely balanced against the risks of failure of CAR-T therapy
- Tocilizumab does not cross the blood brain barrier and so unlike in CRS there is no role for tocilizumab in ICANS
