CAR-T Meeting 2026 | Recommended frequency of ICE assessment to detect neurotoxicity in CAR-T recipients

Jemma:

So we work in a busy haematology unit in Australia where we’ve seen more than 300 patients who’ve received standard of care CAR-T therapy and neurotoxicity is a major complication of CAR-T therapy and so we have a lot of experience caring for these patients and being able to identify and recognise the signs of neurotoxicity. But we’ve also noticed that the patients can deteriorate quite quickly, often in about a fifth of patients requiring ICU admission for severe neurotoxicity. And we conducted a literature review that found that there was no current consensus on how frequently nurses or clinicians should be completing ICE assessments, and so we wanted to create a protocol that helped guide clinicians on the frequency of ICE assessments. 

Ella:

So the ICE assessment is a 10-point neurological test that comes from the ASTCT guidelines. It tests patients’ handwriting, orientation, naming of objects, and attention. Patients are a 10 out of 10 at baseline, and if they drop any points, then that’s a sign of neurotoxicity. 

So our recommendation from the protocol is that patients are assessed eight-hourly from infusion, and then if they show any signs of ICANS, the nurse initiates half-hourly assessments for two hours to monitor for signs of deterioration. If the patient stabilises, they can revert to four-hourly assessments. However, if the patient remains unstable, our recommendation is to continue the half-hourly assessments until they stabilise. The reason we decided to do half-hourly assessments was so that it mirrored our local hospital policies for patients showing signs of clinical deterioration, for example sepsis. This is the same thing we would do for a different indication but we’ve just mirrored it for ICANS. 

Jemma:

So we found that for patients who went on to develop severe ICANS, 93% of those patients initially presented with grade one ICANS, which was often dysgraphia, so a subtle handwriting change. And we found that those patients deteriorated to severe ICANS with a median of 13.8 hours. So for nurses who are looking after these patients, I guess what I would say to them is to take the handwriting change seriously and pay attention to them because once that begins, that’s when they’re at that high risk period for deterioration. Also pay attention to other subtle signs that the nurses are the best position to pick up on. So things like subtle behavioural changes, lack of eye contact, just patients moving around the room differently or behaving strangely, and most importantly, any family or carer concern that the patient is not quite right. We have found anecdotally and through a review of the literature that that’s been reported, while it’s not captured in the ICE assessment, it’s been reported as something that may be associated with ICANS. So trust your nursing senses.

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