Comparison of the European and Japanese guidelines for the management of ischemic stroke

Cerebrovasc Dis. 2013;35(5):402-18. doi: 10.1159/000351753. Epub 2013 May 23.


Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Publication types

  • Comparative Study

MeSH terms

  • Anticoagulants / administration & dosage
  • Anticoagulants / therapeutic use
  • Brain Edema / etiology
  • Brain Edema / prevention & control
  • Brain Ischemia / complications
  • Brain Ischemia / diagnosis
  • Brain Ischemia / drug therapy
  • Brain Ischemia / prevention & control
  • Brain Ischemia / surgery
  • Brain Ischemia / therapy*
  • Decompressive Craniectomy
  • Disease Management
  • Europe
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / therapeutic use
  • Hemodilution
  • Hospital Units / standards
  • Humans
  • Hypertension / complications
  • Hypertension / drug therapy
  • Japan
  • Neuroimaging / standards
  • Neuroprotective Agents / therapeutic use
  • Patient Transfer / standards
  • Platelet Aggregation Inhibitors / administration & dosage
  • Platelet Aggregation Inhibitors / therapeutic use
  • Practice Guidelines as Topic*
  • Referral and Consultation / standards
  • Risk Factors
  • Secondary Prevention / standards
  • Thromboembolism / prevention & control
  • Thrombolytic Therapy / standards


  • Anticoagulants
  • Fibrinolytic Agents
  • Neuroprotective Agents
  • Platelet Aggregation Inhibitors