Optimizing Transcranial Magnetic Stimulation Protocols forPost-Stroke Fluent Aphasia: A Systematic Review of StimulationParametersandClinicalEfficacy

ABSTRACT

Fluent aphasia remains a challenging post-stroke language disorder, and consensus on optimal transcranial magnetic stimulation (TMS) protocols is lacking. This systematic review synthesised 16 studies including randomized controlled trials (RCTs), virtual-lesion experiments, pilot studies, and retrospective study-to evaluate stimulation targets, frequency parameters, and therapeutic outcomes in post stroke fluent aphasia. Across studies, two principal neuromodulatory strategies emerged: inhibitory low-frequency stimulation of right-hemisphere temporal-frontal homologues and excitatory modulation of left-hemispheric language hubs. Inhibiting the right posterior superior temporal gyrus (pSTG) consistently improved auditory comprehension and repetition, whereas modulation of left inferior parietal and temporal regions showed preliminary benefits for lexical-semantic and expressive functions. Virtual-lesion findings further revealed a hierarchical temporalarietal network, with the pMTG serving as a semantic control hub and the STG acting as a phonological semantic integrative interface. However, considerable heterogeneity in stimulation targets, parameters, sample sizes, and outcome measures limits direct protocol standardisation. Overall, current evidence supports TMS as a promising adjunctive therapy for fluent aphasia, while highlighting the need for well-powered trials, neuronavigation-guided targeting, and mechanistic studies integrating multimodal imaging to establish evidence-based, individualised intervention frameworks.