Comparative efficacy of virtual reality and noninvasive brain stimulation on cognitive impairment after stroke: A systematic review and network meta-analysis

Abstract

Background: Post-stroke cognitive impairment (PSCI) is common and lacks well-established non-pharmacolo- gical treatment recommendations. Virtual reality (VR) and noninvasive brain stimulation (NIBS) are increasingly used in neurorehabilitation; however, their relative efficacies remain uncertain.
Objective: To evaluate the effects of VR and NIBS on PSCI using a network meta-analysis.
Study design: Systematic review and network meta-analysis of randomized controlled trials (RCTs).
Methods: The protocol of this systematic review and network meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on May 1, 2025. PubMed, Embase, Web of Science, and the Cochrane Library were searched from their inception to March 19, 2025, for RCTs. Two reviewers in- dependently selected the studies, extracted the data, and assessed the risk of bias according to the Cochrane Handbook. RevMan 5.4 was used for pairwise meta-analyses, and Stata/MP 18.0 for frequentist network meta- analysis of Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores.
Results: Fourteen RCTs comprising 590 patients were included. Network meta-analysis showed that VR and transcranial magnetic stimulation (TMS) were associated with greater estimated improvements in global cog- nition than transcranial direct current stimulation (tDCS). For MMSE, the standardized mean differences (SMDs) versus control were 1.90 (95% Confidence Interval [CI] 0.41-3.39), 0.57 (95% CI 0.27-0.86), and 0.07 (95% CI−0.74-0.89) for VR, TMS, and tDCS, respectively. For MoCA, VR and TMS showed greater numerical im- provements than the control, whereas the effect of tDCS remained uncertain.
Conclusions: Within this indirect evidence network, VR was associated with the largest estimated improvement in global cognitive function after stroke. Among the NIBS modalities, TMS has shown relatively more consistent estimated benefits, whereas the current evidence for tDCS remains inconclusive and requires further high-quality trials.

Keywords

Stroke / cognitive impairment / virtual reality / transcranial magnetic stimulation / transcranial direct current stimulation / network meta-analysis

Ethics approval

Not applicable.

Funding information

This study was supported by the National Key Research and Development Program of China (grant number 2022YFC3601204).

CRediT authorship contribution statement

Qianqian Sun: Investigation, Data Curation, Formal Analysis, Writing - Original Draft. Chunyu Wang: Data Curation, Validation, Writing - Review & Editing. Qiqi Zhang: Methodology, Writing - Review & Editing. Yulong Bai: Conceptualization, Methodology, Supervision. All authors have read and approved the final manuscript.

Data availability

The data supporting the findings of this study are available in the article and supplementary material.

Declaration of Competing Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Declaration of Generative AI and AI-assisted technologies in the writing process

The authors declare that no Generative AI or AI-assisted technolo- gies were used in the writing process.

Acknowledgments

None.

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.hcr.2026.100080.

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