Efficacy of non-invasive brain stimulation for post-stroke sleep disorders: a systematic review and meta-analysis

Abstract

Objective: This study aimed to systematically assess the clinical efficacy of non-invasive brain stimulation (NIBS) for treating post-stroke sleep disorders (PSSD).

Methods: We conducted thorough literature search across multiple databases, including PubMed, Web of Science, EmBase, Cochrane Library, Scopus, China Biology Medicine (CBM); China National Knowledge Infrastructure (CNKI); Technology Periodical Database (VIP), and Wanfang Database, focusing on RCTs examining NIBS for PSSD. Meta-analyses were performed using RevMan 5.4 and Stata 14.

Results: Eighteen articles were reviewed, including 16 on repetitive Transcranial Magnetic Stimulation (rTMS), one on Theta Burst Stimulation (TBS), and two on transcranial Direct Current Stimulation (tDCS). Meta-analysis results indicated that rTMS within NIBS significantly improved the Pittsburgh Sleep Quality Index (PSQI) score (MD = -1.85, 95% CI [-2.99, -0.71], p < 0.05), the 17-item Hamilton Depression Rating Scale (HAMD-17) score [MD = -2.85, 95% CI (-3.40, -2.30), p < 0.05], and serum brain-derived neurotrophic factor (BDNF) levels [MD = 4.19, 95% CI (2.70, 5.69), p < 0.05], while reducing the incidence of adverse reactions [RR = 0.36, 95% CI (0.23, 0.55), p < 0.05]. TBS significantly improved the PSQI score in patients with PSSD (p < 0.05). Conversely, tDCS significantly improved the HAMD-17 score in PSSD patients [MD = -1.52, 95% CI (-3.41, -0.64), p < 0.05]. Additionally, rTMS improved sleep parameters, including Stage 2 sleep (S2%) and combined Stage 3 and 4 sleep (S3 + S4%) (p < 0.05), while tDCS improved total sleep time (TST) and sleep efficiency (SE) (p < 0.05).Subgroup analysis results indicated: (1) Both LF-rTMS and HF-rTMS improved PSQI scores (p < 0.05). (2) Both rTMS combined with medication and rTMS alone improved PSQI scores (p < 0.05). Compared to the sham/blank group, the rTMS group showed improvements in SE, sleep latency (SL), S1%, S3 + S4%, and REM sleep (REM%). The rTMS combined with medication group showed improved SL compared to the medication-only group (p < 0.05).

Conclusion: NIBS effectively improves sleep quality, structure, depression levels, and BDNF levels in PSSD patients, while also being safe. Further investigations into the potential of NIBS in PSSD treatment may provide valuable insights for clinical applications.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, CRD42023485317.

Keywords: insomnia; meta-analysis; non-invasive brain stimulation; sleep disorder; stroke; transcranial direct current stimulation; transcranial magnetic stimulation.

Figure 1

PRISMA flow chart on selection and inclusion of studies.

Figure 2

(A,B) Risk of bias assessment summary according to the Cochrane risk of bias tool. (A) Risk of bias graph; (B) Risk of bias summary.

Figure 3

Effect of NIBS on the total PQSI score of patients with PSSD. (A) Effect of rTMS on the total PQSI score of patients with PSSD; (B) Effect of TBS on the total PQSI score of patients with PSSD; (C) Effect of tDCS on the total PQSI score of patients with PSSD.

Figure 4

(A–G) Effect of NIBS on each sleep parameter of PSG in PSSD patients. Effect of NIBS on TST (min) in patients with PSSD; (B) Effect of NIBS on SE (%) in patients with PSSD; (C) Effect of NIBS on SL (min) in patients with PSSD; (D) Effect of NIBS on S1 (%) in patients with PSSD; (E) Effect of NIBS on S2 (%) in patients with PSSD; (F) Effect of NIBS on S3 + S4 (%) in patients with PSSD; (G) Effect of NIBS on REM (%) in patients with PSSD.

Figure 5

Effect of NIBS on HAMD-17 scores in patients with PSSD.

Figure 6

Effect of rTMS on serum BDNF levels in patients with PSSD.

Figure 7

Forest plot of adverse effects in patients with PSSD treated with rTMS.

Figure 8

Shows an inverted funnel plot using PSQI scores as an outcome indicator.