Neuroimaging-Guided Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Systematic Review and Meta-Analysis

Rates of response to repetitive transcranial magnetic stimulation (rTMS) in obsessive-compulsive disorder (OCD) vary widely. This systematic review and meta-analysis evaluated whether neuroimaging-guided targeting personalization, from fixed-coordinate neuronavigation to individually connectivity-personalized targeting, moderates clinical response, safety, and neural mechanisms in OCD. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, PubMed, the Cochrane Library, and ScienceDirect were searched through July 2026 for randomized and non-randomized studies of neuroimaging-guided transcranial magnetic stimulation (TMS) in OCD. Risk of bias (RoB) was assessed using Cochrane RoB2 for RCTs (randomized controlled trials) and ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies. Random-effects inverse-variance and risk-ratio models pooled Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores and responder rates; non-poolable data were synthesized narratively. Nine study cohorts across eight publications met inclusion criteria (five RCTs and four open-label/single-arm). Pooled analysis of four sham-controlled RCTs showed no significant benefit of neuroimaging-guided TMS on Y-BOCS total score (MD = −0.64, 95% CI = −3.60, 2.32) or responder rate (RR = 1.46, 95% CI = 0.68, 3.15), with moderate heterogeneity. However, trials using individually connectivity-personalized pre-supplementary motor area (pre-SMA) targeting consistently trended toward benefit, while fixed-coordinate neuronavigated trials trended toward null or sham-favoring results. A narrative synthesis of non-poolable and non-randomized studies showed larger, mostly positive within-group reductions in Y-BOCS scores (25%-48%), particularly among patients with moderate disease severity, alongside mechanistic evidence linking individualized connectivity-based targets to symptom improvement. TMS was well tolerated overall, with mild, transient headache being the most common adverse event and no serious safety concerns identified. Overall, neuroimaging-guided TMS showed no pooled benefit in OCD; however, individually connectivity-personalized targeting may be more beneficial than fixed-coordinate approaches, warranting adequately powered trials that directly compare targeting-personalization strategies.