Shuxuetong injection for ischemic stroke: an overview of systematic reviews using different methodological quality assessment tools

Background: Shuxuetong injection possesses blood-activating and stasis-resolving effects with meridian-dredging functions. A growing body of evidence on Shuxuetong injection for the treatment of ischemic stroke has been published; however, no study has comprehensively assessed the methodological quality or clinical conclusions of that evidence. We conducted an overview of systematic reviews (SRs) on Shuxuetong injection for ischemic stroke to synthesize and critically assess the data, conclusions, and methodological quality of the included SRs, aiming to provide reliable evidence-based recommendations for clinical decision-making. Methods: Following a pre-registered protocol on PROSPERO, we conducted systematic searches across eight Chinese and English databases from inception to 25 January 2025. Two reviewers independently screened the SRs according to the eligibility criteria, and any disagreements were resolved through discussion to reach a consensus. Data were extracted for qualitative synthesis. The overlap in primary studies was quantitatively assessed. Methodological quality, reporting completeness, risk of bias, and certainty of evidence were evaluated using AMSTAR-2, PRISMA 2020, ROBIS, and GRADE tools. Results: This overview included 16 SRs. The overlap in primary studies was minimal. Likewise, subgroup analyses comparing conventional therapy (CT) versus Chinese medicine injection combined with CT also indicated low overlap. Methodological evaluation using AMSTAR-2 showed that all included reviews had critically low confidence. Based on PRISMA 2020 (score range: 24.5-31), 13 reviews were graded as meeting moderate-quality criteria and 3 as low quality, with no review rated as high quality. ROBIS assessment revealed a high risk of bias across all included reviews. GRADE evaluations of 125 outcomes showed moderate certainty for 7, low certainty for 21, and very low certainty for 97. Conclusion: Shuxuetong injection demonstrated variable efficacy in improving neurological deficits and activities of daily living, as well as in normalizing hemorheological and other laboratory parameters, with no significant increase in adverse events, indicating a favorable safety profile. However, the credibility of these findings is undermined by the predominantly low or very low quality of the included SRs, as assessed by methodological quality assessment tools. Our findings suggest that the design of future reviews should be rigorously improved in accordance with established methodological criteria to increase confidence in the conclusions. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42025638286, identifier CRD42025638286.