Neurologic toxicity is common and often multifactorial. The primary causes of neurologic injury are (1) drug toxicity, (2) infection, (3) toxic metabolic encephalopathy, and (4) hemorrhage. It is convenient to consider neurologic injury occurring early after transplantation and that occurring late after transplantation separately. Early toxicity tends to be related to immediate problems with conditioning regimen effects. Preexistent neurological problems related to malignancy or metabolic encephalopathy are likely to increase the risk of immediate posttransplantation neurologic symptoms. Later events are often related to prolonged immunoincompetence and the effects of calcineurin inhibitors.

EARLY - POSTTRANSPLANT PERIOD

Calcineurin Inhibitors

• The calcineurin inhibitors (CNI) cyclosporine and tacrolimus are probably the single most frequent cause of neurologic toxicity. The most common manifestations are tremor and burning palmar and plantar dysesthesias. However, headache, depression, confusion, somnolence, and nystagmus may be observed. Seizures may occur, especially in association with hypomagnesemia, hypertension, hypocholesterolemia, infections, and high blood levels of CNI.

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