KUALA LUMPUR, Dec 28 – A new report shows that the vast majority of stroke patients in Malaysia do not get the necessary treatment within the first crucial hours, when a stroke patient’s brain is being damaged beyond repair.
Only 21 per cent of stroke patients were able to be treated at a medical facility within three hours of the onset of symptoms, while the median time from the onset of stroke symptoms to arrival at a hospital was seven hours or more, according to a White Paper on acute stroke care in Malaysia by the Galen Centre for Social Health and Policy that was commissioned and funded by Boehringer Ingelheim (Malaysia).
The delays were attributable to a lack of awareness and recognition of stroke symptoms, as well as accessibility to thrombolysis services.
Thrombolytic therapy (or thrombolysis) is the use of “clot-busting” drugs to break up or dissolve blood clots, which are the main cause of both heart attacks and strokes.
The drugs greatly reduce the risk of death or severe disability in people who suffer from ischaemic stroke, which occurs when a clot blocks the blood flow to the brain. But these drugs must be given within 4.5 hours of symptom onset; otherwise, they are ineffective.
Thrombolytic therapy was first approved for use in public hospitals across Malaysia in 2012. There are 77 hospitals nationwide – 39 in the public sector and 38 in the private sector – providing thrombolysis service.
However, only 11 public hospitals currently provide full access to this treatment on a 24-hour, 7 days a week basis, including Seberang Jaya Hospital in Penang, Queen Elizabeth Hospital in Sabah, Sultanah Nur Zahirah Hospital in Terengganu, and Sarawak General Hospital.
Data from the National Stroke Registry showed that only 0.65 per cent of stroke patients were treated with thrombolysis, out of a sample of 4,762 first-ever ischaemic stroke patients admitted to 13 government hospitals from July 2009 to June 2015.
Galen Centre chief executive Azrul Mohd Khalib – during a symposium held last August 11 at the sidelines of the Malaysia Stroke Conference 2022 in Penang – relayed the experience of a 43-year-old woman with severe hypertension who was working at a bank and was stricken with a stroke episode during a long meeting.
“It was not detected that she had a stroke, and as a result, it was only at the end of the meeting that they realised that she was suffering from a medical emergency, which was not known at the time.
“By the time she was admitted into some form of stroke care, which was nearby, HKL (Kuala Lumpur Hospital) is not that far from where she was working, but it was six hours after which, if you remember the period which is best for patients to get thrombolysis, is 4.5 hours from time of stroke symptom onset, and if possible, within the ‘golden hour’,” Azrul said.
The 60 minutes after the onset of stroke symptoms are known as “the golden hour”. The World Stroke Organisation proposes a door to needle time of 60 minutes to improve stroke patient outcomes. Sixty minutes is the benchmark for stroke workflow from detection to delivery of treatment at a hospital.
“For her, the debilitating situation resulted in her, for more than two years, suffering from a deterioration in the quality of life, limited mobility and almost complete dependence on other people for her living,” Azrul added.
The patient died in July as a result of complications due to a respiratory infection.
“This is a situation that, really, when you look at the facts of the case, could something have been done differently? Most importantly, could she have been brought to treatment, especially thrombolytic treatment, a lot earlier, perhaps, as a form of intervention?
“That’s one of the things when you look at the level of stroke care that’s available today, one of the key issues that have been raised again and again is where do we take a person who we know suffers from a stroke episode to be treated?
“And a significant amount of time is spent wandering the Internet, I kid you not – people Google-ing where to send a patient who is going through a stroke for treatment.
“Very commonly people just send directly to the emergency departments of any hospital for which there could be substandard care. In the end, there is a missed opportunity because you then have to send the patient to another hospital,” Azrul said.
Stroke Services Mostly Available In Klang Valley
More than 40,000 strokes are estimated to occur annually in Malaysia, resulting in almost 14,000 deaths. It is the second leading cause of death and disability in the country and the third most common cause of mortality.
Preliminary data on the “Monitoring Stroke Burden in Malaysia” project found that about 40 per cent of stroke patients were below the age of 60. Another study showed that young stroke, defined as stroke that afflicts those aged between 19 and 50, constituted 16 per cent of hospitalised patients.
Based on current data with an expected 40,000 stroke admissions per year, the cost of stroke management is estimated to be around RM213 million annually.
Despite the prevalence of stroke nationwide, services such as thrombectomy – a procedure that mechanically removes a clot from the brain – are concentrated in the Klang Valley, said Dr Irene Looi, a clinical neurologist at Seberang Jaya Hospital in Penang.
“The majority of thrombectomy centres are in Kuala Lumpur, the Klang Valley region. Even in the north zone, we only have one private and one government centre, which is in Kedah – for the whole of Penang, Kedah, Perlis, and Perak. So, there’s still room for improvement,” Dr Looi said at the symposium.
In addition to thrombectomy centres, Dr Looi also expressed hope of seeing more rehabilitation centres for stroke patients nationwide.
“We want to see more rehabilitation centres like the Cheras Rehabilitation Centre to be in Kedah, in Penang – I’m talking about the north zone because I’m from the north. I’m sure people on the East Coast also have similar hopes, rather than everything being available only in KL,” she said.
Dr Looi highlighted the importance of providing stroke patients with either thrombolysis or thrombectomy treatment quickly to give them a new lease on life.
“Once you have done hyper-acute stroke, you see your patient improve in front of your eyes, your perspective changes,” Dr Looi said.
Acute stroke refers to the first 24 hours of a stroke event. Hyper-acute stroke is when patients are presented within six hours of stroke onset.
“I have been practising for the past 25 years. In the first 15 years when we didn’t do hyper-acute stroke, if there’s a big stroke (patient) that comes in, they will have paralysis of the body, then they lose consciousness, they are paralysed, and they lose their ability to work and to live a quality life – we know that this is the outcome.
“But in the last 10 years of my career, I’ve seen how thrombolysis works and how thrombectomy works,” Dr Looi added.
“If you do some procedure within that ‘golden’ period – undo the clog, and open up the clog within that golden period – your patient, who is supposed to be lying in bed, will just improve within two to three days. They will not end up like what it was supposed to be.”
Among the recommendations made in the White Paper was to decentralise acute stroke care.
It was noted that the greatest improvements were seen when hyper-acute stroke care has been decentralised to several better equipped and staffed hospitals, placing care closer to the community, rather than relying on a small number of regional health care facilities.
“There should be more ‘stroke ready’ hospitals at least one per state, providing 24-hour, seven days a week service through an acute stroke unit (ASU). District hospitals are frequently unutilised and could be used to deliver appropriate stroke care during the early critical period,” the report stated.
More Specialists, Partnerships, and Awareness Of Stroke Can Improve Care
The White Paper further noted that out of 123 registered neurologists in Malaysia, only 31 are practising in hospitals run by the Health Ministry (MOH), while the remaining are attached to university hospitals under the Higher Education Ministry and private health care facilities.
The report called for an increase in the number of neurologists and multidisciplinary health care professionals who can treat stroke and administer thrombolysis needs to fill the expertise gap.
Dr Wong Yee Choon, a consultant neurologist at Pantai Hospital Penang, said while neurologists are aware of stroke, not all are experts in the disease.
“Some may be interested in Parkinson’s, for example, so we should call it neurologists who have a special interest in stroke or a stroke neurologist. A physician who has gone for special training in stroke can also help to fill the gap,” Dr Wong said.
Alternatively, Dr Wong said more public-private partnerships can be established to address manpower and other resource shortages in public health care facilities.
“I think it would be good if we could have some sort of collaboration which is what we have been doing with Seberang Jaya [Hospital]. We can fill the gaps quickly without having to wait for more specialists going for training in the government sector,” Dr Wong said.
He added that the public also needs to be more aware of stroke symptoms and act fast.
The B.E.F.A.S.T acronym is used to check for the most common symptoms of a stroke.
- Balance: Sudden loss of balance or difficulty to coordinate
- Eyesight: Vision is impaired or changed
- Face: Whether one side of the face droops and if it is possible to smile
- Arms: Both arms are raised, and whether one arm drops down instead
- Speech: Check for slurred or strange speech
- Time: If the answer to any of these is yes, immediate medical attention is needed
Stroke is classified as either ischaemic or haemorrhagic.
An ischaemic stroke is caused by blockages or occlusion of the arteries as a result of plaque build-up along the inner lining of arteries. This type of stroke can happen in more than 80 per cent of cases, often suddenly and without early signs or warning.
The typical presentation of an ischaemic stroke is hemiparesis, when one side of the body suddenly experiences weakness or is unable to move.
A hemorrhagic stroke is mainly caused by the rupture of cerebral blood vessels, aneurysms, or as a result of physical trauma. Of those who survive this type of stroke, more than half will experience significant disabilities.
According to the World Health Organization (WHO), for every 10 people who die of stroke, four could have been saved if their blood pressure had been regulated.
SC-MY-02536, Dec 2022