Aside from the fatality rate, stroke often leaves survivors with lifelong disabilities, affecting not only individuals, but entire families.
In response, the Acute Networks Striving for Excellence in Stroke (Angels) initiative aims to help strengthen stroke care nationwide.
Launched in 2016 by German multinational pharmaceutical company Boehringer Ingelheim and endorsed by the European Stroke Organisation (ESO) and the World Stroke Organisation (WSO), the Angels initiative helps hospitals worldwide become “stroke-ready”.
Its goal is straightforward: to improve stroke treatment by providing hospitals with the tools, resources and support necessary to ensure timely, effective care.
By enhancing hospital preparedness and increasing stroke awareness, the initiative helps healthcare teams deliver faster and more effective treatment.
For Sarawak General Hospital (SGH) consultant neurologist and stroke care leader Dr Law Wan Chung, the initiative arrived at a critical time.
“Stroke has consistently been among the top three causes of death in Malaysia over the past 10 to 15 years,” he explains.
“The Angels initiative is very timely for Malaysia, as we urgently need to reduce both mortality and morbidity related to stroke.”
Every minute matters
There are two main types of strokes: ischaemic, caused by a blood clot blocking a vessel in the brain, and haemorrhagic, caused by ruptured blood vessels that result in bleeding.
The most common type of stroke in Malaysia is ischaemic.
“Without oxygen-rich blood, brain cells begin to die within minutes,” Dr Law explains.
“One minute lost means 1.9 million nerve cells are lost.
“Every 15-minute delay significantly reduces the chance of patient recovery.”
He adds: “Treatment must be delivered within four-and-a-half hours of symptom onset.
“This means patients need to reach the hospital within that window, undergo examination, and most importantly, receive brain imaging to determine whether they are eligible for treatment.”
Yet, many patients arrive too late.
Data from the National Stroke Registry shows that only about 35% reach the hospital within that window.
“On average, patients take around seven hours to seek medical care – far beyond the ideal time frame,” Dr Law notes.
If patients arrive early and meet the criteria, doctors will administer intravenous clot-dissolving medication to break down the blockage and restore blood flow.
However, for patients with large vessel occlusion, where a major artery is blocked, medication alone may not be sufficient.
In such cases, a wire may be inserted through a procedure called mechanical thrombectomy – a minimally-invasive method to physically remove the clot.
Together, these two are the most effective treatments for ischaemic stroke patients, and form the core focus of the Angels initiative in Malaysia and globally.
Becoming stroke-ready
Before participating hospitals are chosen for the Angels initiative, they must first meet essential criteria.
This includes having a specialist doctor trained in stroke care and access to neuroimaging facilities such as a CT (computed tomography) scanner or MRI (magnetic resonance imaging).
Once identified, hospitals receive on-site training from the Angels team to establish clear workflows and treatment criteria.
This starts from public awareness and extends to emergency medical services (EMS), i.e. ambulance services.
EMS personnel are trained to recognise stroke symptoms, prioritise patients within the treatment window and alert hospitals in advance.
Upon arrival, whether by ambulance or walk-in, the emergency department rapidly assesses patients and sends them for urgent brain imaging in radiology before a neurologist’s evaluation.
Public awareness also plays a crucial role.
Healthcare providers promote the BE FAST mnemonic to help people recognise warning signs:
- B: Balance problems
- E: Eye or vision disturbance
- F: Facial drooping
- A: Arm or leg weakness
- S: Speech difficulties (slurred or confused speech)
- T: Time, emphasising the urgency of seeking medical help.
“Even one sudden symptom is enough to go to hospital,” Dr Law stresses.
Specific targets
Performance is closely monitored by the Angels team.
Stroke centres are graded gold, platinum or diamond based on key indicators.
These include the total number of stroke patients seen, the minimum number of patients treated over a given period, and the percentage of patients who receive clot-busting treatment.
One critical benchmark is door-to-needle time – i.e. the interval between hospital arrival and treatment – with an international target of 60 minutes.
“At SGH, our initial door-to-needle time was nearly two hours,” Dr Law says.
“Through systematic auditing, we reduced it to under 60 minutes.”
Another key measure tracks the proportion of eligible patients who receive treatment, ensuring that no suitable patient is missed.
Dr Law stresses that leadership is equally vital and that having a dedicated “stroke champion” to coordinate teams and drive improvement is essential.
With only around 170 practising neurologists nationwide and most large hospitals having only one or two, 24-hour coverage remains challenging.
“We cannot rely only on neurologists,” he says.
“This role may also be taken on by physicians, geriatricians or emergency specialists, depending on the hospital’s resources.
“Everyone must work in sync.”
Currently, SGH has earned 10 Gold Awards for hospital performance and one Diamond Award for ambulance performance.
The awards are assessed every three months, requiring hospitals to consistently maintain performance standards.
Beyond individual hospitals, Kuching has been recognised this year (2026) by the WSO as an Angels Region – a designation awarded to areas where community awareness, EMS partnerships and acute hospital care are optimised to deliver better outcomes for stroke patients.
Achieving this requires hospitals, emergency services, local authorities and public educators to work in concert to provide safe, coordinated care for stroke patients in their communities.
Other areas in Malaysia that have received this recognition include the Barat Daya district in Penang and Taiping in Perak.
Introducing a common framework
When Angels was first introduced in Malaysia, stroke services were limited.
In 2017, only about 34 hospitals provided organised stroke-ready treatment, often on a case-by-case basis.
In fact, SGH had already begun 24/7 hyper-acute stroke care as early as 2015, becoming the first hospital in Malaysia to do so.
“The early years were challenging,” Dr Law recalls.
“There was no established system. Everything had to be built from scratch.”
Over time, workflows were refined and systems strengthened.
“We could see that the model worked.”
In 2017, when the Angels initiative was introduced, SGH was the first in East Malaysia to participate and adopt the international protocols and guidelines.
“It allowed us to monitor, audit and expand services – first across the state, and later, nationwide,” he says.
Rather than operating independently, hospitals could work towards shared targets, fostering collaboration and replacing fragmented efforts with a coordinated, standardised approach.
Today, 47 hospitals under the Health Ministry, six under the Higher Education Ministry and 48 private hospitals nationwide provide hyper-acute stroke services.
In East Malaysia, 22 hospitals participate in the initiative, including 12 in Sarawak.
Reaching rural communities
For patients living near urban centres, access to stroke care is relatively straightforward.
In rural Sarawak, however, geography poses significant challenges.
To address this, an integrated ambulance network was established.
“Patients in smaller district hospitals within the Kuching region – including Bau, Serian and Lundu – can be rapidly transferred,” Dr Law explains.
These cluster hospitals lack neuroimaging equipment, requiring transfer to SGH for such facilities.
“If patients present within the treatment window, ambulances may bypass nearer facilities and transport them directly to SGH to have everything done here, including imaging and treatment,” he says.
Today, most Sarawak hospitals with specialist support and neuroimaging provide hyper-acute stroke care, forming referral networks with smaller facilities.
Mechanical thrombectomy, however, remains limited.
SGH is currently the only centre in Sarawak offering the procedure.
For smaller district hospitals outside Kuching, treatment still relies heavily on medication to dissolve clots.
“Patients from other districts may require air transfer.
“Unlike in Peninsular Malaysia, where ambulances can transport patients over long distances by road, Sarawak’s geography presents challenges, as the state is much larger,” he says.
“Ideally, patients should reach Kuching within six hours, although it may still be considered up to 24 hours after symptom onset.
“Upon arrival, doctors reassess whether brain tissue remains viable before proceeding.”
Dr Law emphasises that the most important message the public needs to understand is that stroke is treatable, and in many cases, reversible.
“The earlier treatment is given, the better the chances of full recovery.”
