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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 creatine kinase.

2. Recommendations for hyperacute stroke management during the COVID-19 pandemic are as the followings:

1. 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.

1. Telemedicine
  We encourage for utilization of telemedicine if possible via mobile phone, televideo or phone consultation to reduce the number of personnel during the stroke activation.

1. Personnel safety
  The personnel safety is very important. The stroke activation team should protect themselves and their family.

1. 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.

1. 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.

1. 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.

1. Emergency medical services for stroke
  We encourage education to the public to continue seeking emergency care if they suffer acute stroke symptoms.

1. 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.

#Safetyfirst

#TogetherwefightCOVID

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