Predicting Motor Recovery After Stroke: Utility and Limits of Corticospinal Tract Biomarkers

Background: Corticospinal tract (CST) damage is a major cause of post-stroke motor deficits. However, it remains unclear which estimates of CST damage best predict motor recovery, especially regarding different aspects of motor control. While conventional CST-lesion metrics offer superior feasibility, data-driven machine learning (ML) approaches may better capture patients propensity for task-specific recovery with important implication for their use as future clinical biomarkers. Methods: Providing the first direct longitudinal comparison of these approaches based exclusively on CST-lesion patterns, we evaluated six conventional CST-lesion metrics and a voxel-wise ML approach using clinical MRI data from 127 acute ischemic stroke patients. Acute impairment and outcome (>3 months post-stroke) were assessed for basal and complex motor functions. Conventional CST-lesion metrics and ML were used to predict task-specific motor impairment and outcome. Results: All conventional CST-lesion metrics correlated significantly with both acute impairment and motor outcome across motor domains, with metrics weighted for CST narrowing and tract probability performing best. However, predictive performance for unseen patients was low. ML outperformed conventional markers in predicting acute impairment across motor domains and basal motor outcome, but failed to predict complex motor outcome. Topographically, predictive voxels clustered within and above the posterior limb of the internal capsule, with distinct CST subregions associated with basal versus complex motor impairment, consistent with a task-specific somatotopic organization. Conclusions: The predictive utility of CST biomarkers was task- and timepoint-dependent. While ML may improve predictive performance, complex motor outcome remained difficult to predict, likely reflecting greater reliance on distributed cortical reorganization beyond the CST. By revealing task-specific CST subregions, voxel-wise ML provides an anatomically informed foundation for future predictive models. Such future models should combine CST biomarkers with measures of broader motor network integrity to enable individualized prognosis tailored to specific motor domains and recovery stages.