The immune effector cell-associated encephalopathy (ICE) score can be adapted to better screen for neurological complications in patients with different language backgrounds, sensory or motor needs, a new case series has shown.
The paper reports five instances when clinicians successfully altered items of the ICE score to monitor for immune effector cell-associated neurotoxicity syndrome (ICANS) in CAR T-cell therapy patients with low English proficiency or visual, auditory or physical impairments.
A review of other uses of the ICE score also suggested that omitting aspects from the assessment – particularly sentence writing – can reduce its sensitivity, indicating that clinicians should modify items to suit patients’ needs rather than remove them, whenever possible.
“These cases highlight the need for flexible and patient-tailored strategies and the importance of collaboration between multidisciplinary teams and patients’ families/caregivers when monitoring patients for ICANS after CAR T-cell therapy,” the authors wrote.
The paper, published in BMJ Neurology Open [link here], details how a multidisciplinary team including haematologists and neurologists at The Alfred in Melbourne, Australia, modified the ICE score assessment to be appropriate for five CAR T-cell therapy patients.
For two patients from a Mandarin-speaking background with low English proficiency, the ICE score was modified so that as much of the test as possible was described in simplified written Chinese and presented to the patients on flashcards.
For the visual confrontation naming task, the patient was shown an image of an object and then asked to point to the correct option out of a set of choices written in Chinese.
However, it was emphasised that flashcards for which patients gave incorrect answers at baseline should not be used, “as an incorrect response given post-infusion may be confused for ICANS rather than a lack of vocabulary knowledge”.
The patients also performed the handwriting task in Chinese. In one case, the clinicians recognised a change from the baseline sentence and diagnosed ICANS.
According to the researchers, administering the ICE score with an interpreter “remains best practice,” but modification offers a feasible alternative, particularly when patients need to be assessed quickly and regularly.
For a different patient with congenital blindness, the team used a validated Auditory Naming Task in place of visual confrontation naming, and omitted the sentence writing item.
The patient dropped one point on several occasions, but scored 9/9 when a review by the neuropsychology team suggested some neurocognitive deficits, which reassured the team that ICANS was unlikely and prevented them from unduly escalating treatment.
In another case, the clinicians provided an auditory listening device to a patient with a hearing impairment, who then also used gestures and non-verbal language to complete the ICE score assessment. They consistently scored 10/10 and did not develop ICANS.
In the final case, a patient with multiple sclerosis was able to undertake the ICE score unmodified. They completed the sentence writing task at baseline, despite a tremor and dysmetria, and healthcare staff referred back to this on future assessments.
Sentence writing key
The patient was diagnosed with ICANS when their ICE score dropped to 6/10, with one point lost for sentence writing. They were then treated and recovered, and their ICE score returned to 10/10 24 hours later.
The team also reviewed the history of ICE score use at their institution and found that for nine out of the 14 cases of diagnosed ICANS, the patient’s first imperfect ICE score was 9/10 with a point lost on the sentence writing task.
“If the sentence writing item was omitted from the ICE score in these 14 patients, ICANS detection would have been delayed in six patients and missed in three patients,” the authors wrote.
However, they also highlighted that as the ICE score has limitations, it should “always be considered in conjunction with other clinical measures” in monitoring for ICANS.