KUALA LUMPUR, Nov 25 — Neurologists have called for a national stroke policy like in neighbouring countries, such as Thailand, Vietnam, and Indonesia, to reduce deaths and improve stroke outcomes.
According to Assoc Prof Dr Wan Asyraf Wan Zaidi, a consultant neurologist at Hospital Canselor Tuanku Muhriz UKM, stroke units are limited to tertiary centres; even state hospitals may not necessarily have a stroke unit.
Thrombolysis rates are estimated at less than 3 per cent nationally, with variation by region. Only tertiary centres have achieved a 5 per cent to 10 per cent rate. Thrombolysis is the use of clot-busting drugs to break up or dissolve blood clots, according to Dr Wan Asyraf.
Mechanical thrombectomy rate is at less than 0.7 per cent due to lack of funding, human resources, and infrastructure, he added.
“Door-to-needle times are improving in some centres to less than 60 minutes, but it is inconsistent. Door-to-puncture time is too long of a delay, causing lower benefit of the intervention. As for functional recovery, data is sparse but registry efforts are underway. Lack of central funding and long-term sustainability is important to assist in the national policy plan,” Dr Wan Asyraf told CodeBlue.
The World Stroke Organisation proposes a door-to-needle time of 60 minutes to improve patient outcomes. Door-to-needle time is the interval between hospital arrival and intravenous thrombolytic therapy (IVT) administration. Thrombectomy is a procedure that mechanically removes a clot from the brain.
Dr Wan Asyraf also pointed out that stroke key performance indicators (KPIs) remain largely unstandardised nationally, though there are pilot audits.
Two Malaysian university hospitals have achieved World Stroke Organisation certification for Advance Stroke Centre. The majority of centres have yet to achieve essential stroke centres status.
Across the border, Singapore’s thrombolysis rate [1] was 5.8 per cent in 2022, higher than Malaysia’s estimated rate of less than 3 per cent. Singapore’s door-to-needle time [2] is under 30 minutes.
“Malaysia is lagging behind all metrics, especially thrombectomy access and rehab integration,” said Dr Wan Asyraf.
He noted that developed countries have stroke units in more than 80 per cent of hospitals, national audits, and post-stroke rehab pathways.
In Malaysia, thrombectomy is available only in select urban centres like Kuala Lumpur and Penang, but is absent in most states. Rehabilitation is fragmented, with limited access to multidisciplinary teams outside major hospitals.
Dr Law Wan Chung, a consultant neurologist and head of the neurology unit at Sarawak General Hospital (SGH), said private hospitals in Malaysia generally do not have stroke units as the volume of stroke cases isn’t big enough. Stroke units are also very limited in Ministry of Health (MOH) hospitals, with fewer than five across the country.
Hence, Malaysia’s thrombolysis rate is based on government hospitals.
“On average across Malaysia, excluding the private side, I think our thrombolysis rate is about 2 per cent. Our door-to-needle time is about 60 to 70 minutes,” said Dr Law.
“But based on our registry, on-site to door time, which is the time between a patient getting a stroke and the time they get to the hospital, is generally quite late. On average, I think it’s about seven hours [3].
“We hope to bring the on-site-to-door time shorter. Maybe within two hours, they come to the hospital, so that will give us a chance to treat them with reperfusion therapy.”
Dr Law said Malaysia’s stroke inpatient mortality has improved to about 7 per cent or 8 per cent from 11 per cent in 2016.
“What is striking is that about 20 per cent of our patients will die within one year – for various reasons: either they get an infection or they get a heart attack. One in five will die after the stroke.”
Among Malaysians who survive stroke, only about a third can go back to living independently, lower than other countries.
However, some neighbouring countries are not faring better either. The stroke mortality rate [4] in Vietnam in 2019 ranked fourth highest among 11 neighbouring countries (170 per 100,000 people), following Myanmar (210), Indonesia (197), and North Korea (186).
In Brunei [5], the incidence of death from stroke in the country increased from 24.7 to 35.2 per 100,000 population from 2015 to 2019. Compared to other Southeast Asian nations, Indonesia [6] has the highest age and sex-standardised mortality at 193.3 per 100,000 people.
National Stroke Policy Needed To Boost Efforts Like Thailand, Vietnam, Singapore
Dr Law and Dr Wan Asyraf called for a national stroke policy in Malaysia to improve stroke outcomes via effective initiatives, citing neighbouring countries like Thailand, Vietnam, and Singapore.
Dr Wan Asyraf cited a national stroke fast-track programme in Thailand with universal coverage under its 20-Year National Strategic Plan for Public Health Thailand 2017-2036.
Vietnam developed regional stroke centres and telemedicine networks with partnership from local society and the global Angels initiative, “improving access and outcomes despite resource constraints”.
A 2022 research article [7] published in the Stroke: Vascular and Interventional Neurology journal noted that the number of stroke units in Vietnam increased from a dozen in 2016 to 81 in 2021. In contrast, Malaysia has fewer than five stroke units nationwide.
“Malaysia urgently needs a national stroke policy to improve outcomes, reduce disparities, and guide data-driven planning. Stroke units, thrombolysis, and thrombectomy access remain uneven, and younger Malaysians are increasingly affected,” Dr Wan Asyraf told CodeBlue.
Dr Law cited national stroke policies in Indonesia and Thailand, with the latter having launched theirs years ago. Indonesia’s Stroke Care Transformation Initiatives [8] began in 2021.
Developed countries like South Korea and Australia similarly have national stroke policies.
“Many countries share their experience, saying that stroke used to be in their top causes of mortality, but they managed to reduce it with their national stroke policy. Stroke is no longer in their top three or top five causes of mortality anymore,” he told CodeBlue.
How National Stroke Policy Should Look Like, National KPIs Needed
Dr Wan Asyraf said Malaysia can learn from other countries by investing in advancing stroke care in the country, improving public awareness and emergency triage readiness, centralising stroke care in designated stroke-ready hospitals, using telemedicine to extend expertise to underserved areas, and monitoring KPIs nationally and incentivising performance.
“A national stroke policy should include designation of stroke centres with minimum standards with adequate human resources and funding; integration of primary prevention, pre-hospital, acute care, and rehabilitation; and funding for thrombectomy-capable centres.”
He also listed national KPIs needed for stroke: door-to-needle time, door-to-puncture time, thrombolysis rate, mechanical thrombectomy rate, functional recovery, mortality and stroke unit access, as well as registry-driven audits and feedback loops.
Dr Law said Malaysia can learn from other countries to implement national-level coordination to ensure that stroke treatment is timely and accessible across the country.
Stroke, he noted, has always been among the top three killers in Malaysia for more than 10 to 15 years. The only exception was during the Covid-19 pandemic when stroke fell to number four. But stroke remains among the top five causes of death.
“So if we were to address this issue, as well as the survival and morbidity of patients with a coordinated nationwide policy, more patients can recover to live independently again,” said Dr Law.
The difficulty with a national stroke policy is the fragmentation of the health care system in Malaysia. Private health care providers mainly practise standard of care. Hence Dr Law said a national policy should focus on the public health care system.
“We need to have stroke unit facilities in district hospitals, not only in big tertiary hospitals. We also need to train enough doctors to deliver hyperacute stroke care and make sure that stroke patients are well taken care of after an initial treatment to make sure they don’t develop recurrent complications from stroke,” he said.
MOH has sufficient infrastructure for stroke care, but the main problem is specialist shortages.
“There are only about 160, maybe about 165 neurologists in the country. Among this, only less than 50 are actually serving MOH at the moment. About 30 per cent of neurologists in the country are serving MOH, catering for 60 to 70 per cent of the patient load,” said Dr Law.
“This number is not sufficient to cover all MOH hospitals across Malaysia. So we need to make sure that we have more neurologists. We need to have more stroke doctors that can deliver timely treatment.”
References
- National Registry of Diseases Office (January 2025). Singapore Stroke Registry Annual Report 2022.
- Wang, J.D.J. et al (2025). Improved functional outcomes and cost benefits of door-to-needle time under 30 min in acute ischemic stroke: an observational study. Acute Stroke and Interventional Therapies, Volume 4. Link.
- Zainuddin, A. (2022, December 28). Malaysian Stroke Patients Take Average Seven Hours For Hospital Arrival. CodeBlue. Link.
- Tran, M.C. et al (2025). Comprehensive analysis of stroke epidemiology in Vietnam: Insights from GBD 1990–2019 and RES-Q 2017–2023. Global Epidemiology, 9:100199. Link.
- On, S. et al (2022). The burden and risks factors for intracerebral hemorrhage in a Southeast Asian population. Clinical Neurology and Neurosurgery, 107145. Link.
- Venketasubramanian, N., Yudiarto F.L. & Tugasworo, D. (2022). Cerebrovascular Diseases Extra;12(1):53–57. https://pmc.ncbi.nlm.nih.gov/articles/PMC9149342/
- Duy, T.M. et al (2022). Current State of Stroke Care in Vietnam. Stroke: Vascular and Interventional Neurology, 2(2). Link.
- Kusdiansah, M. et al (2025, September 19). Building Foundation and Bridging Lives: Three Years’ Experience and Future Plan from the Indonesian Stroke Care Transformation Initiatives. World Federation of Neurosurgical Societies. Link.
