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Meta-Analysis
. 2025 Oct;56(10):2976-2987.
doi: 10.1161/STROKEAHA.124.050414. Epub 2025 Aug 4.

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

Brittany Wells  1   2 , Ahmed Nasreldein  3 , Karianne Larsen  4   5 , Frederike van Wijck  1 , Cheryl Carcel  6 , Hanne Christensen  7 , Maren Ranhoff Hov  4   5   8 , Valeria Caso  9 , Mark Woodward  6   10 , Deidre Anne De Silva  11 , Thanh N Nguyen  12 , Vilde Teigene Maloy  4 , Maria Ignacia Allende  6 , Priscilla Abrafi Opare-Addo  13 , Klaus Fassbender  14 , Monika Bachhuber  14 , Else C Sandset  4   5 , Silke Walter  14 ; SESAME Study Group
Collaborators, Affiliations
Meta-Analysis

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

Brittany Wells et al. Stroke. 2025 Oct.

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: anxiety; depression; sex characteristics; stroke; triage.

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Conflict of interest statement

Dr Christensen reports employment by Capital Region of Denmark, the University of Copenhagen, and the American Heart Association and compensation from Boehringer Ingelheim, Bayer Healthcare, Daiichi Sankyo Company, the American Heart Association, Bristol Myers Squibb, Alexion Pharmaceuticals, and Medtronic for consultant services. Dr Caso reports grants from Daiichi Sankyo Company and EVER Neuro Pharma for other services and compensation from Bayer and Boehringer Ingelheim for consultant services. Dr Nguyen reports compensation from Aruna, Medtronic, and Brainomix for consultant services and Kaneka, the American Stroke Association, and Genentech for other services. Dr Sandset reports compensation from AstraZeneca and Bayer for other services. Dr Carcel is an Editorial Board Member of Stroke and Cerebrovascular Diseases and receives research honorarium from Bayer. The other authors report no conflicts.