(596) Double Jeopardy: Immune Checkpoint Inhibitor-Associated Myasthenia Gravis and Hemorrhagic Stroke

Introduction: In the last decade, immune checkpoint inhibitors (ICIs) have become central to cancer treatment. However, because of their unique mechanism of action, ICIs present their own set of adverse events (AEs) called immune-related adverse events. Neurologic immune-related AEs are an emerging area of interest because of the complexity of the nervous system and the potential for long-term morbidity. Although the overall incidence of neurologic AE (NAE) is reported to be about 1%, NAEs constitute 11% of all fatal events secondary to ICIs.

Description: The patient is a 70-year-old male with a history of right posterior cerebral artery stroke, subarachnoid hemorrhage, hepatocellular carcinoma, and status post small bowel/mesenteric mass resection treated with Lenvatinib. Three to four weeks before admission, he had been experiencing left eye ptosis, dyspnea, neck weakness, and difficulty raising his arms and getting up out of a chair. These symptoms were concerning for immune checkpoint inhibitor-related myasthenia gravis. Before this episode, he had no neurologic deficits apart from dizziness and confusion from Lenvatinib. After admission to the ICU, he was started on intravenous immune globulin, high-dose IV methylprednisolone and placed on BIPAP due to worsening hypercarbia and respiratory acidosis. Five days into his ICU admission, he had an acute mental status change with obtundation, right gaze deviation, and left arm weakness. A head CT revealed a large left cerebellar hemorrhage and a small acute right frontal subarachnoid hemorrhage. He had an emergent right frontal EVD placement, decompressive suboccipital hemicraniectomy, and C1 laminectomy and was ultimately transferred to the Neurosurgical ICU. Comfort care measures were pursued after a goal-of-care conversation was held with the family due to his poor prognostic outlook. The patient died peacefully on day 19 of hospitalization.

Discussion: ICIs constitute a promising class of cancer treatment but are associated with several immune-related disorders. In such a scenario, it becomes essential to understand the spectrum of NAEs and diagnose it at the onset to prevent long-term morbidity and mortality—especially complications such as intracranial hemorrhage, which can be life-threatening.