Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis

Brittany Wells; Ahmed Nasreldein; Karianne Larsen; Frederike van Wijck; Cheryl Carcel; Hanne Christensen; Maren Ranhoff Hov; Valeria Caso; Mark Woodward; Deidre Anne De Silva; Thanh N Nguyen; Vilde Teigene Maloy; Maria Ignacia Allende; Priscilla Abrafi Opare-Addo; Klaus Fassbender; Monika Bachhuber; Else C Sandset; Silke Walter; SESAME Study Group

doi:10.1161/STROKEAHA.124.050414

Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis

Brittany Wells^*, Ahmed Nasreldein, Karianne Larsen, Frederike van Wijck, Cheryl Carcel, Hanne Christensen, Maren Ranhoff Hov, Valeria Caso, Mark Woodward, Deidre Anne De Silva, Thanh N Nguyen, Vilde Teigene Maloy, Maria Ignacia Allende, Priscilla Abrafi Opare-Addo, Klaus Fassbender, Monika Bachhuber, Else C Sandset, Silke Walter, SESAME Study Group

^*Corresponding author for this work

Department of Neurology

1 Citation (Scopus)

Abstract

BACKGROUND: Several studies have evaluated sex discrepancies in the prehospital management of patients with acute stroke. This systematic review and meta-analysis aims to summarize reported knowledge about sex differences in dispatch center and emergency medical service management. It proposes a roadmap of questions and the next necessary steps to ensure equitable prehospital stroke care.

METHODS: We conducted a systematic review and meta-analysis, using a random-effects model with inverse weighting. PubMed, CINAHL, EMBASE, and EMCARE were searched for studies investigating sex differences in the prehospital management of patients with suspected and acute stroke. The main outcome was the relative risk (RR) for receiving a correct prehospital stroke diagnosis. Additional outcomes are related to prehospital management and time metrics.

RESULTS: Sixteen studies were included, comprising 571 024 male patients and 622 764 female patients. No relevant risk of bias was detected. Female patients were less often correctly identified as stroke suspects than male patients (RR, 0.92 [95% CI, 0.89-0.96]; I2=73%). No differences were observed in the number receiving a dispatch code stroke (RR, 0.95 [95% CI, 0.88-1.02]; I2=96%), prenotification to hospital by emergency medical service (RR, 0.98 [95% CI, 0.96-1.00]; I2=92%), or conveyance to a stroke center (RR, 0.99 [95% CI, 0.79-1.24]; I2=82%). There was no difference in mean time from emergency call to hospital door (mean difference, 1.12 [95% CI, -0.64 to 2.89] minutes; I2=96%). No conclusion could be drawn for outcomes of on-site clinical management, emergency medical service-to-hospital team interaction, and most of the time metrics due to a lack of data.

CONCLUSIONS: This analysis indicates sex differences in the prehospital recognition of acute stroke. However, significant heterogeneity and a lack of data for most steps of prehospital care also highlight the urgent need for high-quality studies to systematically investigate prehospital management disparity between female and male patients with suspected acute stroke.

REGISTRATION: URL: https://crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023442997.

Original language	English
Journal	Stroke
Volume	56
Issue number	10
Pages (from-to)	2976-2987
Number of pages	12
ISSN	0039-2499
DOIs	https://doi.org/10.1161/STROKEAHA.124.050414
Publication status	Published - Oct 2025

Keywords

Humans
Stroke/therapy
Emergency Medical Services
Female
Male
Sex Characteristics
Sex Factors
sex characteristics
anxiety
depression
stroke
triage

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10.1161/STROKEAHA.124.050414

Cite this

Wells, B., Nasreldein, A., Larsen, K., van Wijck, F., Carcel, C., Christensen, H., Hov, M. R., Caso, V., Woodward, M., De Silva, D. A., Nguyen, T. N., Maloy, V. T., Allende, M. I., Opare-Addo, P. A., Fassbender, K., Bachhuber, M., Sandset, E. C., Walter, S., & SESAME Study Group (2025). Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis. Stroke, 56(10), 2976-2987. https://doi.org/10.1161/STROKEAHA.124.050414

Wells, B, Nasreldein, A, Larsen, K, van Wijck, F, Carcel, C, Christensen, H, Hov, MR, Caso, V, Woodward, M, De Silva, DA, Nguyen, TN, Maloy, VT, Allende, MI, Opare-Addo, PA, Fassbender, K, Bachhuber, M, Sandset, EC, Walter, S & SESAME Study Group 2025, 'Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis', Stroke, vol. 56, no. 10, pp. 2976-2987. https://doi.org/10.1161/STROKEAHA.124.050414

@article{afaa361ce4224495b3e302c30397d1e4,

title = "Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis",

abstract = "BACKGROUND: Several studies have evaluated sex discrepancies in the prehospital management of patients with acute stroke. This systematic review and meta-analysis aims to summarize reported knowledge about sex differences in dispatch center and emergency medical service management. It proposes a roadmap of questions and the next necessary steps to ensure equitable prehospital stroke care.METHODS: We conducted a systematic review and meta-analysis, using a random-effects model with inverse weighting. PubMed, CINAHL, EMBASE, and EMCARE were searched for studies investigating sex differences in the prehospital management of patients with suspected and acute stroke. The main outcome was the relative risk (RR) for receiving a correct prehospital stroke diagnosis. Additional outcomes are related to prehospital management and time metrics.RESULTS: Sixteen studies were included, comprising 571 024 male patients and 622 764 female patients. No relevant risk of bias was detected. Female patients were less often correctly identified as stroke suspects than male patients (RR, 0.92 [95\% CI, 0.89-0.96]; I2=73\%). No differences were observed in the number receiving a dispatch code stroke (RR, 0.95 [95\% CI, 0.88-1.02]; I2=96\%), prenotification to hospital by emergency medical service (RR, 0.98 [95\% CI, 0.96-1.00]; I2=92\%), or conveyance to a stroke center (RR, 0.99 [95\% CI, 0.79-1.24]; I2=82\%). There was no difference in mean time from emergency call to hospital door (mean difference, 1.12 [95\% CI, -0.64 to 2.89] minutes; I2=96\%). No conclusion could be drawn for outcomes of on-site clinical management, emergency medical service-to-hospital team interaction, and most of the time metrics due to a lack of data.CONCLUSIONS: This analysis indicates sex differences in the prehospital recognition of acute stroke. However, significant heterogeneity and a lack of data for most steps of prehospital care also highlight the urgent need for high-quality studies to systematically investigate prehospital management disparity between female and male patients with suspected acute stroke.REGISTRATION: URL: https://crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023442997.",

keywords = "Humans, Stroke/therapy, Emergency Medical Services, Female, Male, Sex Characteristics, Sex Factors, sex characteristics, anxiety, depression, stroke, triage",

author = "Brittany Wells and Ahmed Nasreldein and Karianne Larsen and \{van Wijck\}, Frederike and Cheryl Carcel and Hanne Christensen and Hov, \{Maren Ranhoff\} and Valeria Caso and Mark Woodward and \{De Silva\}, \{Deidre Anne\} and Nguyen, \{Thanh N\} and Maloy, \{Vilde Teigene\} and Allende, \{Maria Ignacia\} and Opare-Addo, \{Priscilla Abrafi\} and Klaus Fassbender and Monika Bachhuber and Sandset, \{Else C\} and Silke Walter and \{SESAME Study Group\}",

year = "2025",

month = oct,

doi = "10.1161/STROKEAHA.124.050414",

language = "English",

volume = "56",

pages = "2976--2987",

journal = "Stroke",

issn = "0039-2499",

publisher = "Wolters Kluwer Health",

number = "10",

}

TY - JOUR

T1 - Sex Differences in Prehospital Stroke Medicine (SESAME)

T2 - A Systematic Review and Meta-Analysis

AU - Wells, Brittany

AU - Nasreldein, Ahmed

AU - Larsen, Karianne

AU - van Wijck, Frederike

AU - Carcel, Cheryl

AU - Christensen, Hanne

AU - Hov, Maren Ranhoff

AU - Caso, Valeria

AU - Woodward, Mark

AU - De Silva, Deidre Anne

AU - Nguyen, Thanh N

AU - Maloy, Vilde Teigene

AU - Allende, Maria Ignacia

AU - Opare-Addo, Priscilla Abrafi

AU - Fassbender, Klaus

AU - Bachhuber, Monika

AU - Sandset, Else C

AU - Walter, Silke

AU - SESAME Study Group

PY - 2025/10

Y1 - 2025/10

N2 - BACKGROUND: Several studies have evaluated sex discrepancies in the prehospital management of patients with acute stroke. This systematic review and meta-analysis aims to summarize reported knowledge about sex differences in dispatch center and emergency medical service management. It proposes a roadmap of questions and the next necessary steps to ensure equitable prehospital stroke care.METHODS: We conducted a systematic review and meta-analysis, using a random-effects model with inverse weighting. PubMed, CINAHL, EMBASE, and EMCARE were searched for studies investigating sex differences in the prehospital management of patients with suspected and acute stroke. The main outcome was the relative risk (RR) for receiving a correct prehospital stroke diagnosis. Additional outcomes are related to prehospital management and time metrics.RESULTS: Sixteen studies were included, comprising 571 024 male patients and 622 764 female patients. No relevant risk of bias was detected. Female patients were less often correctly identified as stroke suspects than male patients (RR, 0.92 [95% CI, 0.89-0.96]; I2=73%). No differences were observed in the number receiving a dispatch code stroke (RR, 0.95 [95% CI, 0.88-1.02]; I2=96%), prenotification to hospital by emergency medical service (RR, 0.98 [95% CI, 0.96-1.00]; I2=92%), or conveyance to a stroke center (RR, 0.99 [95% CI, 0.79-1.24]; I2=82%). There was no difference in mean time from emergency call to hospital door (mean difference, 1.12 [95% CI, -0.64 to 2.89] minutes; I2=96%). No conclusion could be drawn for outcomes of on-site clinical management, emergency medical service-to-hospital team interaction, and most of the time metrics due to a lack of data.CONCLUSIONS: This analysis indicates sex differences in the prehospital recognition of acute stroke. However, significant heterogeneity and a lack of data for most steps of prehospital care also highlight the urgent need for high-quality studies to systematically investigate prehospital management disparity between female and male patients with suspected acute stroke.REGISTRATION: URL: https://crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023442997.

AB - BACKGROUND: Several studies have evaluated sex discrepancies in the prehospital management of patients with acute stroke. This systematic review and meta-analysis aims to summarize reported knowledge about sex differences in dispatch center and emergency medical service management. It proposes a roadmap of questions and the next necessary steps to ensure equitable prehospital stroke care.METHODS: We conducted a systematic review and meta-analysis, using a random-effects model with inverse weighting. PubMed, CINAHL, EMBASE, and EMCARE were searched for studies investigating sex differences in the prehospital management of patients with suspected and acute stroke. The main outcome was the relative risk (RR) for receiving a correct prehospital stroke diagnosis. Additional outcomes are related to prehospital management and time metrics.RESULTS: Sixteen studies were included, comprising 571 024 male patients and 622 764 female patients. No relevant risk of bias was detected. Female patients were less often correctly identified as stroke suspects than male patients (RR, 0.92 [95% CI, 0.89-0.96]; I2=73%). No differences were observed in the number receiving a dispatch code stroke (RR, 0.95 [95% CI, 0.88-1.02]; I2=96%), prenotification to hospital by emergency medical service (RR, 0.98 [95% CI, 0.96-1.00]; I2=92%), or conveyance to a stroke center (RR, 0.99 [95% CI, 0.79-1.24]; I2=82%). There was no difference in mean time from emergency call to hospital door (mean difference, 1.12 [95% CI, -0.64 to 2.89] minutes; I2=96%). No conclusion could be drawn for outcomes of on-site clinical management, emergency medical service-to-hospital team interaction, and most of the time metrics due to a lack of data.CONCLUSIONS: This analysis indicates sex differences in the prehospital recognition of acute stroke. However, significant heterogeneity and a lack of data for most steps of prehospital care also highlight the urgent need for high-quality studies to systematically investigate prehospital management disparity between female and male patients with suspected acute stroke.REGISTRATION: URL: https://crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023442997.

KW - Humans

KW - Stroke/therapy

KW - Emergency Medical Services

KW - Female

KW - Male

KW - Sex Characteristics

KW - Sex Factors

KW - sex characteristics

KW - anxiety

KW - depression

KW - stroke

KW - triage

UR - https://www.scopus.com/pages/publications/105012742915

U2 - 10.1161/STROKEAHA.124.050414

DO - 10.1161/STROKEAHA.124.050414

M3 - Review

C2 - 40755301

SN - 0039-2499

VL - 56

SP - 2976

EP - 2987

JO - Stroke

JF - Stroke

IS - 10

ER -

Sex Differences in Prehospital Stroke Medicine (SESAME): A Systematic Review and Meta-Analysis

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