Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany.
Cerebrovasc Dis. 2013;35(5):402-18. doi: 10.1159/000351753. Epub 2013 May 23.
Different aspects of acute stroke management and strategies for stroke prevention derive from two viewpoints: specific traditional and historical backgrounds and evidence-based medicine from modern randomized controlled trials (RCTs), meta-analysis and authorized clinical practice guidelines (GLs). Regarding stroke, GLs have been published by national and international organizations in different languages, most frequently in English. Cerebrovascular Diseases published the European GLs for the management of ischemic stroke and transient ischemic attacks in 2003, with an update in 2008. At about the same time (in 2004), the first Japanese GLs for the management of stroke appeared in Japanese. The first English version of the updated Japanese GLs was published only in 2011 and included differently approved drugs and drug dosages as compared with other American or European countries.
Since 2011, the authors have met repeatedly and have compared the latest versions of published European and Japanese GLs for ischemic and hemorrhagic strokes. Many aspects have only been addressed in one but left out in the other GLs, which consequently founded the basis for the comparison. Classification of evidence levels and recommendation grades defined by the individual committees differed between both original GLs.
Aspects of major importance were surprisingly similar and hence did not need extensive interpretation. Other aspects of ischemic stroke management differed significantly, e.g. the dosage of recombinant tissue plasminogen activator approved in Japan is lower (0.6 mg/kg) than in Europe (0.9 mg/kg), which derived from different practices in cardiovascular treatment prior to the design of acute ischemic stroke RCTs. Furthermore, comedication with neuroprotective agents (edaravone), intravenous anticoagulants (argatroban) or antiplatelet agents within 1-2 days after stroke onset is recommended in Japan but not in Europe. For cardioembolic stroke prevention, a major difference consists in a higher international normalized ratio target (2.0-3.0) in younger subjects versus in those >70 years (1.6-2.6), without age restrictions in Europe.
This brief survey - when compared with the lengthy original recommendations - provides a stimulating basis for an extended interest among Japanese and European stroke clinicians to learn from their individual experiences and to strengthen efforts for joint cooperation in treating and preventing stroke all around the globe.
急性脑卒中管理的不同方面和脑卒中预防策略源于两种观点：特定的传统和历史背景以及现代随机对照试验（RCT）、荟萃分析和授权临床实践指南（GL）的循证医学。关于脑卒中，不同国家和国际组织已经以多种语言发布了 GL，最常使用的语言是英语。《脑血管病杂志》于 2003 年发布了欧洲缺血性卒中和短暂性脑缺血发作管理 GL，并于 2008 年进行了更新。大约在同一时间（2004 年），日本发布了第一版脑卒中管理 GL。2011 年才首次出版了更新后的日本 GL 的英文版，其中包含了与其他美国或欧洲国家不同的批准药物和药物剂量。
自 2011 年以来，作者多次会面，比较了最新版已发表的欧洲和日本缺血性和出血性脑卒中 GL。许多方面只在一个 GL 中得到了阐述，而在另一个 GL 中被遗漏，这也成为了比较的基础。两个原始 GL 中分别由各自委员会定义的证据水平分类和推荐等级也有所不同。
非常重要的方面惊人地相似，因此不需要进行广泛的解释。缺血性脑卒中管理的其他方面则存在显著差异，例如日本批准的重组组织型纤溶酶原激活剂剂量（0.6mg/kg）低于欧洲（0.9mg/kg），这是由于急性缺血性脑卒中 RCT 设计之前心血管治疗的不同实践造成的。此外，日本建议在脑卒中发病后 1-2 天内联合使用神经保护剂（依达拉奉）、静脉抗凝剂（阿加曲班）或抗血小板药物，而欧洲则不建议这样做。在心源性栓塞性脑卒中预防方面，一个主要区别在于年轻患者的国际标准化比值目标较高（2.0-3.0），而大于 70 岁的患者目标较低（1.6-2.6），而欧洲没有年龄限制。
与冗长的原始建议相比，这份简要的调查为日本和欧洲脑卒中临床医生提供了一个刺激的基础，使他们能够从各自的经验中学习，并加强在全球范围内治疗和预防脑卒中方面的合作。
