Update on Repetitive Transcranial Magnetic Stimulation in Post-Stroke Cognitive Rehabilitation: A Systematic Review of Randomized Clinical Trials

Background: We synthesized evidence from randomized clinical trials (RCTs) published between 2019 and 2025 on repetitive transcranial magnetic stimulation (rTMS) in post-stroke cognitive impairment (PSCI) and compared different stimulation parameters, cortical targets, and combinations with rehabilitation interventions. Methods: A systematic review according to PRISMA guidelines examined the RCTs applying rTMS in adults with PSCI compared with control or sham groups. The primary outcome was improvement in cognitive function and functional outcomes measured with standardized scales. Results: Fifteen studies, involving a total of 732 patients, were included. The most frequently investigated were high-frequency (≥10 Hz) stimulation protocols of the left dorsolateral prefrontal cortex, with treatment cycles ranging from 2 to 6 weeks. Overall, rTMS was generally safe and well tolerated, with rare and mild adverse events. Several studies reported improvements in cognitive performance following rTMS, although effects were variable across trials and need caution in light of heterogeneity in stimulation protocols, sample sizes, outcome measures, and methodological quality. In most cases, rTMS or intermittent theta burst stimulation combined with structured cognitive training yielded greater cognitive and functional gains than stimulation or rehabilitation alone. This suggests a positive interaction between rTMS and cognitive training, although current evidence does not yet allow definitive conclusions. Conclusions: rTMS appears to be a promising strategy for post-stroke cognitive rehabilitation, particularly for attention and executive functioning. However, heterogeneity in stimulation protocols and outcome measures, along with limited sample sizes and short follow-up, reduces the certainty and comparability of current evidence. The widespread reliance on global screening tools may further underestimate domain-specific effects. Future multicentre trials with standardized protocols and more sensitive cognitive assessments are needed to clarify efficacy and guide further clinical application of rTMS in PSCI.