Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) Consensus Grading for Adults

• This tool should not be the sole basis for care; use clinical judgment and a complete clinical evaluation to guide management.
• Perform a neurologic assessment before administration of immune effector cell engaging therapy and then daily afterwards while hospitalized. 
• Non-neurological factors (e.g., sedation, infection, metabolic derangements) can confound grading; evaluate and treat alternative causes.

Per NCCN Guidelines for Management of CAR T-Cell-Related Toxicities, consider the following approach:

• Grade 1: 
  
  • Supportive care. 
  • Consider 1 dose of dexamethasone 10 mg IV.
• Grade 2: 
  
  • Supportive care.
  • Give 1 dose of dexamethasone 10 mg IV, then reassess.
  • Repeat every 6–12 hours if no improvement.
• Grade 3: 
  
  • ICU care.
  • Give dexamethasone 10 mg IV every 6 hours or methylprednisolone 1 mg/kg every 12 hours. 
  • Consider adding anakinra 100 mg every 6 hours if not responsive to steroids or if symptoms worsen.
  • Consider repeat CT head or MR brain every 2–3 days for persistent Grade 3 or higher neurotoxicity.
• Grade 4: 
  
  • ICU care.
  • Consider mechanical ventilation for airway protection.
  • Administer high-dose steroids.
  • Consider adding anakinra 100 mg every 6 hours if not responsive to steroids.
  • Consider repeat CT head or MR brain every 2–3 days for persistent Grade 3 or higher neurotoxicity.
  • Treat convulsive status epilepticus per institutional guidelines.

• Evaluate for papilledema or other signs of high intracranial pressure (ICP) in Grade 3 or Grade 4 cases, per NCCN guidelines. 
• If elevated ICP is excluded, consider diagnostic lumbar puncture to evaluate Grade 3–4 neurotoxicity.