# ICANS after CAR T-cell therapy: ICE score, ASTCT grading, steroids and seizure management

Source: https://onco.cc/protocols/icans-grading-and-management/  
OnCo record `icans-grading-and-management` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

In the weeks after CAR T-cell therapy, some people become confused, struggle to find words or write, become very sleepy, or rarely have seizures. This is ICANS. Nurses check a short test of orientation, naming, writing and counting (the ICE score). Steroids such as dexamethasone treat it, and most people recover. A carer who notices confusion or odd speech should call the centre at once.

## Summary

ICANS is graded by ASTCT 2019 with the 10-point ICE score (orientation 4, naming 3, following commands 1, writing 1, attention 1): 7 to 9 is grade 1, 3 to 6 grade 2, 0 to 2 grade 3, and 0 because the patient cannot be roused grade 4. The overall grade is the worst of the ICE score, level of consciousness, seizures, motor weakness and raised intracranial pressure or cerebral oedema. Children under 12 are assessed with the Cornell Assessment of Pediatric Delirium (CAPD), where 9 or more counts as grade 3. Headache alone is not a marker; expressive aphasia is the most specific early sign.

SITC 2020: baseline ICE (or CAPD) before infusion; ICE twice daily in the first week after axicabtagene ciloleucel. Work-up with CRP, blood count, metabolic panel, fibrinogen and PT/INR, and consider head CT, EEG and MRI, without delaying treatment. Steroids for grade 3 or 4 (LE: 4) and for grade 2 after CD28-costimulated products such as axicabtagene ciloleucel and brexucabtagene autoleucel (LE: 3); consider them for grade 2 after 4-1BB products such as tisagenlecleucel. Give at least 2 doses and taper fast on improvement (LE: 3). With low-grade CRS and ICANS together, treat the ICANS first with steroids, since tocilizumab may worsen neurotoxicity (LE: 5). Levetiracetam for seizures (LE: 4); prophylaxis only for high-risk patients (LE: 4), and EBMT/JACIE 2019 does not recommend it routinely. Suspected cerebral oedema goes to intensive care at once. Dexamethasone 0.5 mg/kg, at most 10 mg a dose, and methylprednisolone 2 mg/kg/day are the commonly used steroids (SITC).

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: ICANS management; immune effector cell-associated neurotoxicity syndrome; ICE score; CAR-T neurotoxicity; CAPD score for children
- Tags: protocol; cell-therapy; car-t; acute-oncology

## Connected records

- protocols: [Acute oncology telephone triage: the 24-hour helpline and the UKONS red, amber and green grading](https://onco.cc/protocols/acute-oncology-telephone-triage/), [Cytokine release syndrome after CAR T-cell therapy: ASTCT grading, tocilizumab and steroids](https://onco.cc/protocols/crs-grading-and-management/), [IEC-HS after CAR T-cell therapy: recognition and stepwise treatment](https://onco.cc/protocols/iec-hs-management/), [Infection screening, prophylaxis and immunoglobulin replacement around CAR T-cell therapy](https://onco.cc/protocols/car-t-infection-prevention/), [T-cell engaging bispecific antibodies: step-up dosing, monitoring and outpatient delivery](https://onco.cc/protocols/bispecific-step-up-dosing/)
- technologies: [CAR-T cell therapy](https://onco.cc/technologies/car-t/)
- drugs: [Axicabtagene ciloleucel](https://onco.cc/drugs/axicabtagene-ciloleucel/), [Brexucabtagene autoleucel](https://onco.cc/drugs/brexucabtagene-autoleucel/), [Ciltacabtagene autoleucel](https://onco.cc/drugs/ciltacabtagene-autoleucel/), [Dexamethasone](https://onco.cc/drugs/dexamethasone/), [Idecabtagene vicleucel](https://onco.cc/drugs/idecabtagene-vicleucel/), [Lisocabtagene maraleucel](https://onco.cc/drugs/lisocabtagene-maraleucel/), [Obecabtagene autoleucel](https://onco.cc/drugs/obecabtagene-autoleucel/), [Tisagenlecleucel](https://onco.cc/drugs/tisagenlecleucel/), [Tocilizumab](https://onco.cc/drugs/tocilizumab/)
- institutions: [Society for Immunotherapy of Cancer](https://onco.cc/institutions/sitc/)
- terms: [Cytokine release syndrome and ICANS: grading and management](https://onco.cc/terms/lymphoma-tx-crs-icans/), [ICANS (neurotoxicity)](https://onco.cc/terms/icans/)

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