Summary of manifestations and management of neurotoxicity from methotrexate, CAR T cells, and blinatumomab
| Characteristic . | Methotrexate . | CAR T cells . | Blinatumomab . |
|---|---|---|---|
| Frequency of neurotoxicity | 3%-7% | 28%-64% | 24%-54% |
| Risk factors | Older age, Hispanic ethnicity, history of elevated transaminases | High disease burden, high-grade CRS, preexisting neurologic deficits | Older age, nonwhite race, prior neurologic events, >2 prior salvage therapies |
| Time of onset from therapy initiation | 3-11 days | 4-6 days | Median 9 days in adult patients, may be earlier in pediatric patients |
| Common signs/symptoms | Seizures, encephalopathy, SLS | Seizures, dysphasia, encephalopathy, cerebral edema | Seizures, tremor, somnolence, encephalopathy |
| Average time to resolution | 1-4 days | 5-11 days | 1-5 days |
| MRI findings | Leukoencephalopathy | Cerebral edema, leptomeningeal enhancement, multifocal microhemorrhages | Insufficient data available |
| Management | Supportive care | Neurocritical care, steroids, anticonvulsants, anticytokine therapies | Steroids, interruption of blinatumomab infusion |
| Characteristic . | Methotrexate . | CAR T cells . | Blinatumomab . |
|---|---|---|---|
| Frequency of neurotoxicity | 3%-7% | 28%-64% | 24%-54% |
| Risk factors | Older age, Hispanic ethnicity, history of elevated transaminases | High disease burden, high-grade CRS, preexisting neurologic deficits | Older age, nonwhite race, prior neurologic events, >2 prior salvage therapies |
| Time of onset from therapy initiation | 3-11 days | 4-6 days | Median 9 days in adult patients, may be earlier in pediatric patients |
| Common signs/symptoms | Seizures, encephalopathy, SLS | Seizures, dysphasia, encephalopathy, cerebral edema | Seizures, tremor, somnolence, encephalopathy |
| Average time to resolution | 1-4 days | 5-11 days | 1-5 days |
| MRI findings | Leukoencephalopathy | Cerebral edema, leptomeningeal enhancement, multifocal microhemorrhages | Insufficient data available |
| Management | Supportive care | Neurocritical care, steroids, anticonvulsants, anticytokine therapies | Steroids, interruption of blinatumomab infusion |