Neurologic adverse events associated with immune checkpoint inhibitors
| Toxicity . | Presentation . | Evaluation . | Recovery . |
|---|---|---|---|
| Encephalitis | Confusion, depressed level of consciousness, and behavioral changes | Brain MRI, LP | Most recover with early treatment; high morbidity/mortality with delayed diagnosis |
| Aseptic meningitis | Headache, neck stiffness, photophobia, nausea, and vomiting | Brain and spine MRI, LP | Most recover completely |
| Hypophysitis | Headache, fatigue, and endocrine dysfunction | Brain MRI, LP, hormone levels | Permanent damage to pituitary in most; replacement hormone therapy necessary |
| Cerebellar toxicity | Ataxia, nystagmus, and vertigo | Brain MRI, LP | Most recover |
| Transverse myelitis | Back pain, weakness/paralysis, sensory loss, and bladder/bowel dysfunction | Spine MRI, LP | Most recover |
| Cranial and peripheral neuropathy | Facial palsy, trigeminal neuralgia, paresthesias, sensory loss, weakness, and autonomic symptoms | Brain MRI and LP (if cranial nerve involvement), EMG/NCS | Most recover |
| Guillain-Barré syndrome | Ascending sensory loss, weakness, areflexia, facial diplegia, dysphagia, and autonomic dysfunction | Spine MRI, LP, EMG/NCS | Variable prognosis; mortality associated with respiratory muscle involvement |
| Myasthenia gravis | Muscle weakness, diplopia, and ptosis | Serum for AChR antibodies, EMG | Fatal in one-third of patients |
| Myositis | Proximal muscle weakness, pain, dysphagia, ptosis, diplopia, and dyspnea | CK, aldolase, EMG, consider muscle biopsy | Most patients recover completely |
| Toxicity . | Presentation . | Evaluation . | Recovery . |
|---|---|---|---|
| Encephalitis | Confusion, depressed level of consciousness, and behavioral changes | Brain MRI, LP | Most recover with early treatment; high morbidity/mortality with delayed diagnosis |
| Aseptic meningitis | Headache, neck stiffness, photophobia, nausea, and vomiting | Brain and spine MRI, LP | Most recover completely |
| Hypophysitis | Headache, fatigue, and endocrine dysfunction | Brain MRI, LP, hormone levels | Permanent damage to pituitary in most; replacement hormone therapy necessary |
| Cerebellar toxicity | Ataxia, nystagmus, and vertigo | Brain MRI, LP | Most recover |
| Transverse myelitis | Back pain, weakness/paralysis, sensory loss, and bladder/bowel dysfunction | Spine MRI, LP | Most recover |
| Cranial and peripheral neuropathy | Facial palsy, trigeminal neuralgia, paresthesias, sensory loss, weakness, and autonomic symptoms | Brain MRI and LP (if cranial nerve involvement), EMG/NCS | Most recover |
| Guillain-Barré syndrome | Ascending sensory loss, weakness, areflexia, facial diplegia, dysphagia, and autonomic dysfunction | Spine MRI, LP, EMG/NCS | Variable prognosis; mortality associated with respiratory muscle involvement |
| Myasthenia gravis | Muscle weakness, diplopia, and ptosis | Serum for AChR antibodies, EMG | Fatal in one-third of patients |
| Myositis | Proximal muscle weakness, pain, dysphagia, ptosis, diplopia, and dyspnea | CK, aldolase, EMG, consider muscle biopsy | Most patients recover completely |
AChR; acetyl choline receptor; CK, creatine kinase; EMG, electromyography; LP, lumbar puncture; NCS, nerve conduction studies.