{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T05:50:16Z","timestamp":1791352216581,"version":"4.3.1"},"reference-count":44,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:00:00Z","timestamp":1791331200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Tongue examination is central to traditional Chinese medicine (TCM) syndrome differentiation after stroke, but its diagnostic accuracy has not been evaluated using contemporary diagnostic test accuracy (DTA) methods.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We searched PubMed, Embase, Web of Science, CNKI, Wanfang, and VIP from inception to 23 February 2026 (PROSPERO: CRD420261288502). Track 1 studies of manual tongue diagnosis were pooled using bivariate or univariate random-effects models; Track 2 studies of artificial intelligence (AI)-assisted models were synthesized narratively according to SWiM. Risk of bias was assessed with QUADAS-2 and the certainty of Track 1 evidence with GRADE-DTA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Ten studies from mainland China included 3,437 participants: six manual-diagnosis studies (\n                      <jats:italic>N<\/jats:italic>\n                      \u202f=\u202f2,191) and four AI-assisted studies (\n                      <jats:italic>N<\/jats:italic>\n                      \u202f=\u202f1,246). Because evidence certainty was very low and reference-standard independence was not assured, all estimates were treated as exploratory agreement with existing syndrome-classification processes rather than clinically validated diagnostic accuracy. The Deficient-Cold Tongue cluster showed pooled specificity of 0.97 (95% CI: 0.87\u20131.00) and a positive likelihood ratio (PLR) of 31.0 (95% CI: 2.8\u2013341.6). The Greasy Coating cluster showed pooled sensitivity of 0.83 (95% CI: 0.52\u20130.96), specificity of 0.80 (95% CI: 0.68\u20130.88), PLR of 4.1 (95% CI: 2.5\u20136.8), and a negative likelihood ratio of 0.21 (95% CI: 0.06\u20130.71). Blood Stasis Tongue showed low sensitivity and unstable, heterogeneous estimates. The small analyzable evidence base contrasted with the much larger descriptive literature.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Current evidence remains too uncertain to support manual tongue diagnosis for routine or standalone clinical use, and applicability is largely limited to mainland Chinese TCM stroke-care settings. Manual and AI-assisted approaches require prospective multicenter validation using independent syndrome adjudication that excludes the index tongue feature. Future studies should stratify analyses by stroke etiology and report calibration and clinical utility for AI models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Systematic review registration<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link>PROSPERO<\/jats:ext-link>\n                      , CRD420261288502.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2026.1874937","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T04:53:45Z","timestamp":1791348825000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Diagnostic accuracy of tongue diagnosis for stroke syndrome differentiation in traditional Chinese medicine: a systematic review, meta-analysis, and narrative synthesis of artificial intelligence-assisted models"],"prefix":"10.3389","volume":"17","author":[{"given":"Yibo","family":"Huang","sequence":"first","affiliation":[{"name":"School of Acupuncture, Moxibustion and Tuina, Anhui University of Chinese Medicine","place":["Hefei, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiashun","family":"Yin","sequence":"additional","affiliation":[{"name":"School of Medical Information Engineering, Anhui University of Chinese Medicine","place":["Hefei, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siyuan","family":"Shao","sequence":"additional","affiliation":[{"name":"The Second Affiliated Hospital of Anhui University of Chinese Medicine","place":["Hefei, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pengyu","family":"Jiang","sequence":"additional","affiliation":[{"name":"The First Affiliated Hospital of Anhui University of Chinese Medicine","place":["Hefei, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zilong","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Clinical Medicine, North Anhui Health Vocational College","place":["Suzhou, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"Xu","sequence":"additional","affiliation":[{"name":"First Clinical Medical College, Anhui University of Chinese Medicine","place":["Hefei, Anhui, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,10,7]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"973","DOI":"10.1016\/S1474-4422(24)00369-7","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990\u20132021: a systematic analysis for the global burden of disease study 2021","volume":"23","year":"2024","journal-title":"Lancet Neurol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1016\/S1474-4422(21)00252-0","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990\u20132019: a systematic analysis for the global burden of disease study 2019","volume":"20","year":"2021","journal-title":"Lancet Neurol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"949","DOI":"10.3967\/bes2024.162","article-title":"Report on cardiovascular health and diseases in China 2023: an updated summary","volume":"37","year":"2024","journal-title":"Biomed Environ Sci"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1016\/j.neuroscience.2024.12.043","article-title":"Unveiling synergies: integrating TCM herbal medicine and acupuncture with conventional approaches in stroke management","volume":"567","author":"Liu","year":"2025","journal-title":"Neuroscience"},{"key":"ref5","volume-title":"Criteria of Diagnosis and Therapeutic effect of Diseases and Syndromes in Traditional Chinese medicine (ZY\/T001.1\u201394)","year":"1994"},{"key":"ref6","doi-asserted-by":"crossref","DOI":"10.1002\/9781119756194","volume-title":"Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 2.0","author":"Deeks","year":"2023"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1017\/s1481803500009891","article-title":"Incorporation bias in studies of diagnostic tests: how to avoid being biased about bias","volume":"10","author":"Worster","year":"2008","journal-title":"CJEM"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"516473","DOI":"10.1155\/2012\/516473","article-title":"Visual agreement analyses of traditional Chinese medicine: a multiple-dimensional scaling approach","volume":"2012","author":"Lo","year":"2012","journal-title":"Evid Based Complement Alternat Med"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"108074","DOI":"10.1016\/j.compbiomed.2024.108074","article-title":"A review of traditional Chinese medicine diagnosis using machine learning: inspection, auscultation-olfaction, inquiry, and palpation","volume":"170","author":"Tian","year":"2024","journal-title":"Comput Biol Med"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"436","DOI":"10.1038\/nature14539","article-title":"Deep learning","volume":"521","author":"LeCun","year":"2015","journal-title":"Nature"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1038\/s41591-018-0300-7","article-title":"High-performance medicine: the convergence of human and artificial intelligence","volume":"25","author":"Topol","year":"2019","journal-title":"Nat Med"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"e078378","DOI":"10.1136\/bmj-2023-078378","article-title":"TRIPOD+AI statement: updated guidance for reporting clinical prediction models that use regression or machine learning methods","volume":"385","author":"Collins","year":"2024","journal-title":"BMJ"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"3283","DOI":"10.1038\/s41591-025-03953-8","article-title":"The STARD-AI reporting guideline for diagnostic accuracy studies using artificial intelligence","volume":"31","author":"Sounderajah","year":"2025","journal-title":"Nat Med"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"982","DOI":"10.1016\/j.jclinepi.2005.02.022","article-title":"Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews","volume":"58","author":"Reitsma","year":"2005","journal-title":"J Clin Epidemiol"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1016\/0197-2456(86)90046-2","article-title":"Meta-analysis in clinical trials","volume":"7","author":"DerSimonian","year":"1986","journal-title":"Control Clin Trials"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"l6890","DOI":"10.1136\/bmj.l6890","article-title":"Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline","volume":"368","author":"Campbell","year":"2020","journal-title":"BMJ"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"529","DOI":"10.7326\/0003-4819-155-8-201110180-00009","article-title":"QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies","volume":"155","author":"Whiting","year":"2011","journal-title":"Ann Intern Med"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1016\/j.jclinepi.2019.12.020","article-title":"GRADE guidelines: 21 part 1. Study design, risk of bias, and indirectness in rating the certainty across a body of evidence for test accuracy","volume":"122","author":"Sch\u00fcnemann","year":"2020","journal-title":"J Clin Epidemiol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: an updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"388","DOI":"10.1001\/jama.2017.19163","article-title":"Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA statement","volume":"319","author":"McInnes","year":"2018","journal-title":"JAMA"},{"key":"ref21","author":"Higgins","year":"2024"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"1293","DOI":"10.1002\/sim.4780121403","article-title":"Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations","volume":"12","author":"Moses","year":"1993","journal-title":"Stat Med"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"607","DOI":"10.1214\/aoms\/1177729756","article-title":"Transformations related to the angular and the square root","volume":"21","author":"Freeman","year":"1950","journal-title":"Ann Math Stat"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1136\/bmj.327.7414.557","article-title":"Measuring inconsistency in meta-analyses","volume":"327","author":"Higgins","year":"2003","journal-title":"BMJ"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1056\/NEJM197507312930513","article-title":"Letter: nomogram for Bayes theorem","volume":"293","author":"Fagan","year":"1975","journal-title":"N Engl J Med"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1016\/j.jclinepi.2005.01.016","article-title":"The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed","volume":"58","author":"Deeks","year":"2005","journal-title":"J Clin Epidemiol"},{"key":"ref27","volume-title":"GRADEpro GDT: GRADEpro Guideline Development Tool","year":"2026"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"687","DOI":"10.3348\/kjr.2024.0598","article-title":"Reporting guidelines for artificial intelligence studies in healthcare (for both conventional and large language models): what's new in 2024","volume":"25","author":"Park","year":"2024","journal-title":"Korean J Radiol"},{"key":"ref29","volume-title":"Stata Statistical Software: Release 19","year":"2025"},{"key":"ref30","volume-title":"Clinical Observation Study on Ischemic Stroke Recovery period based on eye Diagnosis and TCM Tongue Diagnosis","author":"Yi","year":"2024"},{"key":"ref31","first-page":"94","article-title":"Observation of tongue manifestations in patients with acute hemorrhagic stroke","volume":"21","author":"Zheng","year":"2010","journal-title":"Hainan Med J"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"6079595","DOI":"10.1155\/2018\/6079595","article-title":"A preliminary study on discriminant analysis of syndrome types in the recovery period of stroke in traditional Chinese medicine","volume":"2018","author":"Gan","year":"2018","journal-title":"Biomed Res Int"},{"key":"ref33","first-page":"1552","article-title":"Clinical study on tongue diagnosis in acute cerebrovascular disease","volume":"17","author":"Liu","year":"2008","journal-title":"J Emerg Tradit Chin Med"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1016\/j.dcmed.2025.03.010","article-title":"Analysis of clinical characteristics and diagnostic prediction of qi deficiency and blood stasis syndrome in acute ischemic stroke","volume":"8","author":"Xu","year":"2025","journal-title":"Digit Chin Med"},{"key":"ref35","volume-title":"Clinical Observation Study on Tongue Manifestations, TCM Syndrome types, and Related Factors in Patients with acute Ischemic Stroke","author":"Cao","year":"2021"},{"key":"ref36","first-page":"670","article-title":"Quantitative study on tongue diagnosis in patients with stroke","volume":"21","author":"Cui","year":"2001","journal-title":"Chin J Integr Tradit West Med"},{"key":"ref37","first-page":"1460","article-title":"Classification study of tongue images for TCM syndrome differentiation in stroke based on convolutional neural networks","volume":"43","author":"Wang","year":"2023","journal-title":"J Hunan Univ Chin Med"},{"key":"ref38","volume-title":"Identification of Tongue Image Features in Patients with Qi-Deficiency and Blood-Stasis Syndrome of Acute Cerebral Infarction Based on Deep Learning","author":"Wang","year":"2024"},{"key":"ref39","volume-title":"Identification of Tongue Image Features in Patients with Liver-Qi Stagnation Syndrome of Acute Cerebral Infarction Based on Deep Learning (Master\u2019s thesis)","author":"Han","year":"2024"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"926","DOI":"10.1056\/NEJM197810262991705","article-title":"Problems of spectrum and bias in evaluating the efficacy of diagnostic tests","volume":"299","author":"Ransohoff","year":"1978","journal-title":"N Engl J Med"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1177\/0272989X06295361","article-title":"Decision curve analysis: a novel method for evaluating prediction models","volume":"26","author":"Vickers","year":"2006","journal-title":"Med Decis Mak"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"703","DOI":"10.1001\/jama.1994.03510330081039","article-title":"Users\u2019 guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients?","volume":"271","author":"Jaeschke","year":"1994","journal-title":"JAMA"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"351","DOI":"10.2307\/2087176","article-title":"Ecological correlations and the behavior of individuals","volume":"15","author":"Robinson","year":"1950","journal-title":"Am Sociol Rev"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"1583","DOI":"10.1109\/JPROC.2024.3507831","article-title":"Domain generalization for medical image analysis: a review","volume":"112","author":"Yoon","year":"2024","journal-title":"Proc IEEE"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1874937\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T04:53:50Z","timestamp":1791348830000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1874937\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,7]]},"references-count":44,"alternative-id":["10.3389\/fneur.2026.1874937"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1874937","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,7]]},"article-number":"1874937"}}