Dear Editor, The recent article by Singh et al.,1 “Prevalence and associations of post‑stroke restless legs syndrome: A cross‑sectional study,” contributes important clinical data to a topic that remains incompletely delineated despite its relevance to post‑stroke morbidity. Among 107 stroke survivors, the authors identified 14 cases of de novo restless legs syndrome (RLS), with a prevalence rate of 13.1%. This estimate is consistent with previous reports, highlighting the need for gaining a comprehensive understanding of the bidirectional relationship between cerebrovascular disease and RLS. To contextualize these findings, we conducted a focused review using PubMed with the terms “restless legs syndrome” and “stroke,” without any restrictions. The search was conducted up to December 2025. The detailed methodology—including the search strategy, eligibility criteria, and quality assessment—is provided in the Supplementary Material. Our aim was to examine two aspects of the RLS–stroke interface, as follows: (1) the risk of incident stroke among individuals with established RLS and (2) the proportion of stroke patients who subsequently developed RLS. Both directions of this association must be evaluated to clarify the mechanistic links and to inform long‑term surveillance strategies. For examining the risk of stroke in individuals with RLS, we identified five longitudinal cohort studies reporting adjusted hazard ratios (HRs) for incident cerebrovascular events. After the log transformation of HRs and random‑effects pooling, the results revealed that RLS was associated with a significantly higher risk of stroke (HR = 1.71; 95% confidence interval CI: 1.07–2.75) Figure 1. A fixed‑effect model yielded an even higher estimate (HR = 2.32). These findings differ from those of earlier meta‑analyses, which did not demonstrate a significant association; this lack of an association might be due to the smaller number of available studies at that time.2 In addition to the cohorts examined in the previous meta‑analyses, our review included two additional longitudinal cohorts. Given the observational nature of the data, these results should be considered hypothesis-generating rather than definitive. The expanded evidence base now supports the hypothesis that RLS is a marker of increased vascular risk, although residual confounding and reverse causation are possible.3 The potential contributors include nocturnal sympathetic overactivity, fragmentation of slow‑wave sleep, endothelial impairment, and systemic inflammatory signaling.4 Although the causal inference remains limited, the consistency of the association suggests that individuals with RLS are at increased cerebrovascular vulnerability.Figure 1: Forest plots of the adjusted hazard ratios of stroke between patients with restless legs syndrome and controls reported in the included prospective observational studiesWe also identified 16 studies assessing new‑onset RLS after stroke, encompassing 3,120 patients. Across these reports, the pooled proportion of post‑stroke RLS was 12.38% (95% CI: 11.18–13.70) Figure 2; individual studies demonstrated rates ranging from approximately 2% to 26%. The prevalence rate of 13.1% reported by Singh et al. is an intermediate value within this expected range, reinforcing the reproducibility of the prevalence rate of post‑stroke RLS across heterogeneous cohorts.1 The varying prevalence rate is attributed to differences in study design, timing of RLS assessment, stroke subtype, and lesion localization.Figure 2: Forest plot of the prevalence estimates and 95% confidence intervals across individual studies evaluating the outcome of interest. All estimates are shown as proportions (0–1 scale) on the x‑axis.Taken together, the literature supports a bidirectional association between stroke and RLS. Individuals with RLS may exhibit a modestly increased risk of subsequent stroke, and stroke may lead to the development of RLS in approximately one in eight patients.5 These observations are based on observational data and should be interpreted with caution. Future research should be conducted to delineate the neuroanatomical substrates most strongly associated with post‑stroke RLS, evaluate its prognostic significance, and determine whether the targeted management of RLS favorably influences vascular outcomes. Acknowledgement None. Author contribution A. Research project: 1. Conception: Jamir Pitton Rissardo 2. Organization: Ana Leticia Fornari Caprara 3. Execution: Jamir Pitton Rissardo and Ana Leticia Fornari Caprara B. Statistical analysis: 1. Design: Jamir Pitton Rissardo and Ana Leticia Fornari Caprara 2. Execution: Jamir Pitton Rissardo 3. Review and Critique: Ana Leticia Fornari Caprara C. Manuscript preparation: 1. Writing of the first draft: Jamir Pitton Rissardo and Ana Leticia Fornari Caprara 2. Review and Critique: Jamir Pitton Rissardo and Ana Leticia Fornari Caprara Ethical compliance statement The authors have reviewed the journal’s ethical publication guidelines and attest that this submission adheres to them. The authors confirm that institutional ethical clearance was not required for this work. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Rissardo et al. (Fri,) studied this question.