Effectiveness of different repetitive transcranial magnetic stimulation modalities on sleep function and depression in patients with post-stroke sleep disorders: a systematic review and network meta-analysis of randomized controlled trials

Background Post-stroke sleep disorders are common chronic complications that can severely impair patient recovery. Although post-stroke sleep disorders have been effectively treated using repetitive transcranial magnetic stimulation (rTMS), the relative efficacy of varied rTMS modalities remains unclear. Methods We conducted a comprehensive search of the Cochrane Library, PubMed, Embase, Web of Science, Scopus, China National Knowledge Infrastructure, and Wanfang Data databases up to July 2024. Two investigators independently selected and analyzed the relevant studies, as well as evaluated the risk of bias, indirectness, and overall confidence in the network. A frequentist network meta-analysis was conducted to compare differences in the Pittsburgh Sleep Quality Index (PSQI) scores, sleep efficiency, and Hamilton Depression Scale (HAMD-17) scores following treatment with various rTMS modalities. Results A total of 15 randomized controlled trials involving 1,113 patients with post-stroke sleep disorders were included. The rTMS protocols comprised low-frequency stimulation of the right dorsolateral prefrontal cortex (DLPFC), low-frequency stimulation of the bilateral DLPFC (b-DLPFC), and high-frequency stimulation of the left DLPFC. Compared with pharmacotherapy alone, low-frequency rTMS of the right DLPFC significantly improved PSQI scores, HAMD-17 scores, and sleep efficiency. Additionally, low-frequency rTMS of the b-DLPFC significantly improved PSQI scores and sleep efficiency compared with pharmacotherapy alone. In contrast, high-frequency rTMS of the left DLPFC showed no significant improvements in the PSQI scores, HAMD-17 scores, or sleep efficiency in comparison with pharmacotherapy alone. Moreover, no significant differences in efficacy were observed among the three rTMS modalities. Finally, probabilistic ranking suggested that low-frequency rTMS of the right DLPFC was optimal for enhancing PSQI scores, low-frequency rTMS of the b-DLPFC was most effective for improving sleep efficiency, and low-frequency rTMS of the right DLPFC was the most beneficial for reducing HAMD-17 scores. Conclusion Low-frequency rTMS targeting the right DLPFC offers superior overall effectiveness in improving sleep function and alleviating depression in patients with post-stroke sleep disorders. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD42024589437 , identifier CRD42024589437.