Repetitive transcranial magnetic stimulation for post-stroke aphasia: a meta-analysis of stimulation and hemispheric dynamics

Post-stroke aphasia (PSA) is a common and debilitating consequence of stroke. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising intervention to support language recovery. In this meta-analysis, we systematically reviewed randomized controlled trials (RCTs) from PubMed, the Cochrane Library, and Embase up to November 1, 2024. A random-effects model was used to calculate pooled standardized mean differences (SMDs) and 95% confidence intervals (CIs). Subgroup analyses examined the effects of protocol type (excitatory vs inhibitory), individualized targeting, stroke chronicity, and stimulation site. Twenty-six RCTs met the inclusion criteria. Across all included studies, the combined sample comprised 419 participants in active rTMS groups and 318 in control or sham groups. The pooled results demonstrated a significant positive effect of rTMS on language recovery in PSA (SMD = 0.80; 95% CI, 0.48-1.11; P < 0.00001). Both inhibitory and excitatory protocols were effective, with the greatest gains observed when inhibitory stimulation targeted the right inferior frontal gyrus (pars triangularis) and was administered during the subacute phase post-stroke. Individualized rTMS did not demonstrate a statistically significant advantage over standard protocols. These findings support rTMS as an effective therapeutic approach for PSA and highlight the importance of optimizing stimulation parameters, timing, and interhemispheric dynamics. Further research is warranted to refine rTMS strategies and identify patient-specific predictors of treatment response.