3 rd April 2020, at the moment we have 3116 positive COVID-19 patients with 50
mortality. Today, most of the critical care services in the country are allocated
for SARI and COVID-19 patients. The Malaysia Stroke Council is concerned on the
safety of both patients and health care personnel with the current extraordinary
COVID-19 crisis. The usual rigorous process to create the national guideline will
go through an extensive literature review. None is possible at the moment as we
are in lockdown and the world is still in the process of understanding and
adapting to this pandemic. Therefore, we produce this temporary statement as a
suggestion on the necessary measures, which will be updated the soonest when
more evidences available to us.
1. COVID-19 and neurology disease
The COVID-19 disease primarily manifested as a respiratory disease. However
there are case series from China that described the commonest neurological
manifestations are dizziness, headache and encephalopathy. In certain patients,
they may also complain of anosmia, dysgeusia and muscle injury with raised
2. Recommendations for hyperacute stroke management during the
COVID-19 pandemic are as the followings:
Personal Protective Equipment (PPE) All patients should be treated as potentially infected, and this includes our stroke
patients. In order to stratify the risk, we suggest to ask for the contact history,
travelling history, body temperature, and history of any Influenza like symptoms
or respiratory symptoms at the first moment of contact with PPE available
(surgical mask or full PPE based on the risk). At the same time we should try to
minimize the number personnel to reduce exposure and utilization of PPE
whenever possible. This is the best time to create a good teamwork among the
stroke activation team members.
Telemedicine We encourage for utilization of telemedicine if possible via mobile phone,
televideo or phone consultation to reduce the number of personnel during the
Personnel safety The personnel safety is very important. The stroke activation team should
protect themselves and their family.
COVID-19 sampling The suspected Person Under Investigation (PUI) should be tested according to
updated Malaysia Ministry of Health guideline (refer MOH guideline). At the
moment the RT-PCR COVID-19 test is preferred.
Stroke imaging protocol The imaging protocol should be tailored according to the patient’s risk to
minimize duration of exposure to healthcare staff. It can simplified in the high
risk subgroup patients until the necessary management has been done. The
CT/MRI suite to be thoroughly cleaned in between patients.
Hyperacute reperfusion treatment The eligible patient for acute stroke treatment will be given appropriate
treatment such as thrombolysis/thrombectomy to the extent that possible.
For strokethrombectomy it is preferably done in a negative pressure room or
HEPA filtered room.
Emergency medical services for stroke We encourage education to the public to continue seeking emergency care if they
suffer acute stroke symptoms.
Stroke admission Stroke cases should be admitted to stroke care unit whenever possible. In cases
of PUI or positive COVID-19, they should be isolated as guideline. This is
important as stroke patients commonly suffer from multiple medical problem
which may lead to poor outcome if they acquire the COVID-19 disease. Any
aerosol generated procedure should be avoided i.e. nasogastric tube insertion etc.