Methodological choices strongly modulate the sensitivity and specificity of lesion-symptom mapping analyses

Lesion mapping results can vary substantially as a function of specific analysis parameters, but the extent to which individual methodological choices interact to modulate the sensitivity and specificity of results is not clear. Here, we employed a large-scale simulation approach to inform practical recommendations for lesion symptom mapping studies. Routine clinical imaging from 959 stroke survivors (mean age = 72.5, 49.3% female) was used to conduct 384,780 lesion mapping analyses based on simulated behavioural data. Each simulated analysis used different combinations of plausible sample inclusion criteria, analysis parameters (e.g., correction factors), analysis types (e.g., univariate vs. multivariate), and underlying target correlates. Simulated analysis accuracy (Dice similarity coefficient and percent coverage of target correlates) was compared across designs. Overall, analysis accuracy varied widely and was substantially modulated by the specific design used. Analyses that maximised lesion coverage by including large and diverse samples reliably outperformed analyses using more restricted samples. Analyses using direct total lesion volume controls outperformed analyses using other (or no) volume corrections across all accuracy measures. False discovery rate corrections yielded the best performance in terms of target coverage, while permutation corrections yielded the best Dice coefficients. While multivariate approaches were more accurate than univariate analyses in terms of Dice coefficient, univariate analyses generated higher target hit rates and percent target coverage. These results identify specific analysis designs suitable for studies aiming to maximise their sensitivity and/or specificity to underlying critical correlates, while highlighting the inferential strengths and weaknesses of these complementary approaches.