Electroencephalography in patients with immune effector cell-associated neurotoxicity syndrome (ICANS)

Background & objectives

Seizures are a recognized complication of immune effector cell-associated neurotoxicity syndrome (ICANS) from chimeric antigen receptor T cell therapy (CAR-T). Our objective was to characterize continuous (electroencephalogram) EEG data during ICANS to understand EEG patterns in the broader clinical context.

Methods

Clinical and EEG data was collected retrospectively from 2018 to 2023 in patients who underwent CAR-T for cancer and subsequently developed ICANS. Baseline cognitive status, brain MRI findings, and neurological involvement of tumor were noted. Infectious and metabolic status was documented.

Results

Twenty-nine patients met inclusion criteria. Those who underwent EEG during ICANS had higher grades of ICANS (p < 0.001). Clinical seizures were rare but correlated with increased mortality from ICANS (p = 0.008). Thirty-six 24-h EEG recordings were analyzed across 16 patients. No seizure activity was captured on any EEG. Diffuse slowing was found in 97.2 % of EEGs, with 19.4 % showing focal slowing in the frontal and/or temporal leads. Non-epileptic triphasic morphology occurred in 41.7 % of studies. After controlling for concurrent toxic-metabolic derangements, ICANS remained the only explanation in six cases.

Discussion

Clinical seizure events were rare and highly associated with death from ICANS. No persistent epileptiform activity was found on continuous EEGs in our cohort after initiation of antiepileptics with or without other immunotherapy for ICANS, suggesting that prolonged EEG may be of limited utility once electrographic seizures have been ruled out. Frequent triphasic waves were noted in ICANS alone and should not exclude ICANS as the cause of encephalopathy after CAR-T.