Is Less More After Thrombolysis? Debating Intensive Stroke Monitoring at ISC 2026

As stroke systems of care evolve, clinicians are increasingly torn between the known safety of traditional, aggressive monitoring protocols and the potential benefits of streamlined, less intensive workflows. Determining best practices can be difficult, and the 2026 International Stroke Conference (ISC) pitted renowned stroke experts against one another to discuss optimal approaches.

Debates at the International Stroke Conference 2026 centered on optimal treatment of ischemic stroke in the modern era. | Image credit: Aliaksandr Marko - stock.adobe.com

In a session on controversies in ischemic stroke care, one debate centered on intensive monitoring for patients on reperfusion therapy.

Intensive Neurovascular Monitoring: Safety Net or Resource Drain?

The debate centered on the OPTIMISTmain trial, which challenged the 30-year-old tradition of waking stroke patients every 15 to 60 minutes for neurological checks after receiving intravenous thrombolysis (IVT).1

Before Craig Anderson, BMedSc, MBBS, PhD, professor of neurology and epidemiology at the George Institute for Global Health in Australia and president-elect of the World Stroke Organization and OPTIMISTmain lead author, began his talk, the audience was polled on their best practices for monitoring after IVT. A whopping 74% of respondents reported watching all patients closely with frequent neurological checks in the intensive care unit (ICU), while 22% watch those who meet certain criteria (like low National Institutes of Health Stroke Scale [NIHSS] scores and no endovascular thrombectomy [EVT]) outside of the ICU with less frequent checks after 2 hours of high-intensity monitoring, and 4% watch most patients outside of the ICU regardless of NIHSS.

Nursing care for stroke has become more complicated and demanding, and from Anderson’s perspective, patients receiving reperfusion therapy do not require intensive, frequent monitoring based on modern research. He argued that the medical community has followed antiquated monitoring protocols "like sheep" for decades without challenging whether such high-intensity monitoring is truly beneficial.

“It's very disruptive to be waking patients quite frequently to do a neuro exam, and it's very disruptive to sleep, and that may have adverse impacts in terms of their recovery,” he added.

He presented a low-intensity monitoring protocol developed at Johns Hopkins—moving to checks every 2 hours, then every 4 hours after an initial 2-hour stability period—as a way to modernize care. This protocol was examined in the OPTIMISTmain trial, which included 4922 participants at 114 hospitals. Importantly, a low-risk subgroup with mild to moderate neurological impairment was chosen.1

Although the trial did show evidence that low-intensity monitoring is noninferior to standard monitoring in patients with a mild or moderate level of neurological impairment who underwent thrombolysis for acute ischemic stroke, the evidence was weak. Still, there was no significant difference in recovery or mortality between low- and high-intensity groups, Anderson noted.

“It was extremely well received by the nursing community in a range of focus groups, which we undertook, and we made the recommendation that you could consider incorporating this,” Anderson said, noting that the choice of a 1.15 risk ratio as the margin for noninferiority was somewhat harsh.

The other argument for less intense monitoring, especially in the US where ICU costs are very high, comes from an economic analysis of the OPTIMISTmain protocol, which found a 95.91% likelihood of cost savings if this protocol is used.2

The Case for Keeping a Closer Eye on Recovering Patients

Nishita Singh, MD, DM, MSc, assistant professor at the University of Manitoba in Canada and the Heart & Stroke, Research Manitoba, and University of Manitoba provincial chair for clinical stroke research, used the same evidence to support her counterargument, which is that aggressive monitoring is a critical risk-mitigation strategy, not a luxury.

“This debate matters, because we all know that reperfusion therapy intentionally alters cerebrophysiology, and the complications of these therapies are time-dependent, they are clinically silent initially, and they're almost always detected by our nurses before you take the patients to the scanner,” Singh said.

With less intensive monitoring, she argued, there could be more missed complications that would have been caught by bedside clinical exams or neurological exams and vital sign monitoring. She cited specific examples, such as if a nurse detects a drop in NIHSS, the patient can be rushed to a scanner to identify symptomatic intracerebral hemorrhage—which can be reversed—or reocclusion, which can be treated with EVT.

“Are we really prepared to miss early detection in exchange for workflow efficiency by this proposed method of low-frequency monitoring?” she asked the audience.

She got into the weeds of the OPTIMISTmain trial design and outcomes, arguing that a 15% threshold for noninferiority is not too conservative. Digging into the statistics, she argued that the upper bounds of the confidence interval touched the noninferiority margin and did not show noninferiority.

“I would argue that this is not weak evidence, but there is no evidence based on these trial results to say that less frequent monitoring is not inferior to frequent monitoring,” Singh said.

In rebuttal, Anderson joked that Singh’s arguments hinged on fear and argued that we cannot yet monitor the brain as well as other organs, like the heart, and therefore intensive monitoring serves less of a purpose and overburdens nurses.

“It's not taking the nursing resource away,” Anderson said. “It's using your nurses in a smarter way to manage the patient for the best outcome, which is ultimately our goal. If you're in a very well-resourced environment and you can have this, go for it and [keep] everything intensive, but it's not the same around the world.”

For her rebuttal, Singh argued again that intensive monitoring can improve outcomes by catching deterioration earlier. There are actionable steps, she explained—and those steps are time-dependent.

In closing, the combatants agreed to disagree (and remain friends), and a second audience poll found that 6% of respondents would switch from an intensive to nonintensive monitoring approach in practice. The debate underscored a central tension in modern stroke care—how to balance patient safety with evolving evidence and strained resources in a rapidly changing clinical landscape.

References

1. Anderson CS, Summers D, Ouyang M, et al. Safety and efficacy of low-intensity versus standard monitoring following intravenous thrombolytic treatment in patients with acute ischaemic stroke (OPTIMISTmain): an international, pragmatic, stepped-wedge, cluster-randomised, controlled non-inferiority trial. Lancet. 2025;405(10493):1909-1922. doi:10.1016/S0140-6736(25)00549-5

2. Xu L, Ouyang M, Atkins ER, et al. Low-intensity monitoring for mild-to-moderate acute ischemic stroke is cost saving: economic evaluation for OPTIMISTmain. Stroke. Published online January 29, 2026. doi:10.1161/STROKEAHA.125.053506