Table 2.
Neurotoxicity Grading and Treatment*.
| Grade 1 | Grade 2 | Grade 3 | Grade 4 | |
|---|---|---|---|---|
| Disorientation° | Mild | Moderate | Severe | Severe |
| Dysgraphia° | Present | Present | limited assessment | limited assessment |
| Aphasia° | Word finding difficulty | Moderate aphasia | Severe global aphasia | Severe global aphasia |
| Dyskinesia | Mild tremor | Intermittent facial twitching, tremors or myoclonus | Continuous facial twitching and myoclonus | Continuous facial twitching and myoclonus requiring airway protection. |
| Attention and consciousness° | Inattentive or mild delirium | Lethargic or moderate delirium | Obtundation/stupor or severe delirium | Coma or severe delirium requiring airway protection. |
| Seizure | _______ | _______ | Partial seizures, non-convulsive or convulsive seizures | Convulsive or non-convulsive status epilepticus. |
| Cerebral Edema | _______ | _______ | Grade 1–2 papilledema and associated headache, nausea and vomiting | Grade 3–5 cerebral edema, or clinical signs of herniation such as Cushing’s triad, posturing, cranial nerve VI palsy and diabetes insipidus. |
| Motor strength | 5/5 | 5/5 | 3–4/5 | 0–2/5 |
| Supportive care | • Imaging (CT or MRI brain) and EEG • Frequent neurologic exam • Consider seizure prophylaxis • Consider and treat other causes of encephalopathy as needed • Lumbar puncture if no contraindication |
• Imaging (CT brain or MRI) and EEG • Frequent neurologic exam • Consider seizure prophylaxis • Consider and treat other causes of encephalopathy as needed • Lumbar puncture if no contraindication |
• Imaging (CT or MRI brain) and EEG • Frequent neurologic exam • Treatment of seizures including benzodiazepines, levetiracetam or other anti-epileptic drugs • Consider and treat other causes of encephalopathy as needed • Lumbar puncture if no contraindication |
• Imaging (CT or MRI brain) and continuous EEG • Frequent neurologic exam • Management of status epilepticus as per institutional guidelines • Consider and treat other causes of encephalopathy as needed |
| Treatment | • Supportive care and close monitoring for progression • Consider Tocilizumab if associated to CRS symptoms |
• Supportive care and close monitoring for progression • Consider Tocilizumab if associated to CRS symptoms |
• Corticosteroids: Dexamethasone 10 mg IV q 6hr or equivalent to methylprednisolone** • Consider Tocilizumab if associated to CRS symptoms |
• Corticosteroids: Methylprednisolone IV 1gm/day** • Consider Tocilizumab if associated to CRS symptoms |
*
Based on Common Terminology criteria for Adverse Events (CTCAE) guidelines and experience at our institutions.
°
Consider diagnostic tools to grade severity such as those recommended by Neelapu et. al5