Efficacy of repetitive transcranial magnetic stimulation at different frequencies for post-stroke cognitive impairment: A network meta-analysis
Clinical Snapshot
PICO Framework
| P — Population | Stroke survivors with post-stroke cognitive impairment (PSCI) |
| I — Intervention | Repetitive transcranial magnetic stimulation (rTMS) at various frequencies and anatomical sites |
| C — Comparator | Different rTMS protocols (high-frequency vs low-frequency, left vs right vs bilateral stimulation) |
| O — Outcomes | Cognitive function measured by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE), functional outcomes measured by Modified Barthel Index (MBI) |
Bottom Line
This network meta-analysis of 37 RCTs suggests high-frequency rTMS may improve cognitive and functional outcomes in post-stroke cognitive impairment. High-frequency left dorsolateral prefrontal cortex stimulation showed the greatest cognitive benefit on MoCA scores, while bilateral stimulation was most effective for functional outcomes. However, the evidence quality is uncertain due to limited methodological reporting, absence of precision measures, and lack of heterogeneity assessment. The clinical significance of the reported mean differences (2.93-3.38 points on cognitive scales) requires careful interpretation against minimal clinically important differences. While promising, these findings require validation through high-quality multicentre trials before routine clinical implementation. Australian clinicians should consider current TGA approvals and local expertise when evaluating rTMS for stroke rehabilitation.
Key Findings
P Value: Not reported
Effect Size: HFL-rTMS: MD=3.38 (MoCA); HFR-rTMS: MD=2.93 (MMSE); HFB-rTMS: MD=13.47 (MBI)
Primary Outcome: Cognitive improvement measured by MoCA, MMSE, and functional improvement by MBI
Nnt Or Sensitivity: SUCRA rankings: HFL-rTMS 87.6% (MoCA), HFR-rTMS 79.7% (MMSE), HFB-rTMS 89.6% (MBI)
Confidence Interval: Not reported
Clinical Application
Requires specialized rTMS equipment and trained operators; availability varies across Australian centres rTMS devices are TGA-approved for depression; off-label use for PSCI would require careful consideration. Limited PBS coverage for stroke rehabilitation applications. RACGP guidelines don't currently include rTMS for cognitive rehabilitation Stroke survivors with cognitive impairment in rehabilitation settings
Abstract
PURPOSE: Post-stroke cognitive impairment (PSCI) affects nearly half of stroke survivors, necessitating effective interventions. This Bayesian network meta-analysis evaluated the efficacy of various repetitive transcranial magnetic stimulation (rTMS) protocols for PSCI. METHODS: We systematically searched PubMed, Cochrane Library, and Chinese databases up to December, 2025, including 37 randomized controlled trials (2543 patients) comparing rTMS protocols with different frequencies (low/high) and sites (left/right). Outcomes were measured using the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), and Modified Barthel Index (MBI). RESULTS: Results indicated that high-frequency left dorsolateral prefrontal cortex stimulation (HFL-rTMS) most effectively improved MoCA scores (MD=3.38, SUCRA=87.6%), high-frequency right-sided stimulation (HFR-rTMS) ranked highest for MMSE improvement (MD=2.93, SUCRA=79.7%), and high-frequency bilateral stimulation (HFB-rTMS) yielded the greatest MBI enhancement (MD=13.47, SUCRA=89.6%). CONCLUSIONS: High-frequency rTMS demonstrated superior efficacy in cognitive and functional recovery. HFL-rTMS, HFR-rTMS, and HFB-rTMS are recommended as optimal interventions for MoCA, MMSE, and MBI outcomes, respectively. Further studies are warranted to validate stimulation parameters and expand multicenter evidence for clinical application.
References
- 1.Liu, C., Li, X., Chen, H., Zhang, Y., Chen, N., Sun, J., Cheng, S., & Zhang, W. (2026). Efficacy of repetitive transcranial magnetic stimulation at different frequencies for post-stroke cognitive impairment: A network meta-analysis. Behavioural Brain Research, 116132. https://doi.org/10.1016/j.bbr.2026.116132
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