Introduction Sex disparities in stroke treatment have gained increasing interest, especially since women have worse post-stroke functional outcomes compared with men. Existing studies provide conflicting evidence, with some indicating women have longer delays and less often receive acute treatment, whereas others show no differences between men and women. We aimed to explore sex differences in acute treatment modalities and time metrics of patients with acute ischemic stroke (AIS) in a real-world setting. Secondly, we examined whether functional outcomes differed by sex and whether this was influenced by treatment timing. Methods We analyzed data from the Dutch Acute Stroke Audit, a prospective consecutive registry of AIS patients from 72 hospitals in the Netherlands, between 2017 and 2020. We captured data on type of treatment administered (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]), time metrics (onset-to-door time [OTDT], door-to-needle and door-to-groin times), and functional outcomes at three months (modified Rankin scale [mRS]). The association between sex and poor outcome (mRS 3-6) was assessed with Cox proportional hazard models stratified by type of treatment and adjusted for age, additionally for National Institute of Health Stroke Scale (NIHSS) and OTDT. Results Of the 58,632 patients, 26,941 (46%) were women. Compared with men, women were, older (mean age 74.6 versus 71.0, p<.001) and presented with slightly higher NIHSS-scores (median 3 [IQR 2-7] versus 3 [IQR 1-6], p<.001). Treatment modalities distribution (no treatment, IVT, EVT) was similar between women and men (64%; 29%; 10% versus 63%; 30%; 9%, p=.16). Women had a slightly longer OTDT (median 145 versus 139 minutes, p<.01). Women had increased odds of poor outcomes (OR 1.49 [95%CI 1.34-1.56]). This was still statistically significant after adjusting for age and NIHSS-score (OR 1.22 [95%CI 1.16-1.28]). Neither treatment modality nor OTDT had an additional influence on this association. Conclusion ...