Ground-truth validation of uni- and multivariate lesion inference approaches

Lesion analysis aims to reveal the causal contributions of brain regions to brain functions. Various strategies have been used for such lesion inferences. These approaches can be broadly categorized as univariate or multivariate methods. Here we analysed data from 581 patients with acute ischaemic injury, parcellated into 41 Brodmann areas, and systematically investigated the inferences made by two univariate and two multivariate lesion analysis methods via ground-truth simulations, in which we defined a priori contributions of brain areas to assumed brain function. Particularly, we analysed single-region models, with only single areas presumed to contribute functionally, and multiple-region models, with two contributing regions that interacted in a synergistic, redundant or mutually inhibitory mode. The functional contributions could vary in proportion to the lesion damage or in a binary way. The analyses showed a considerably better performance of the tested multivariate than univariate methods in terms of accuracy and mis-inference error. Specifically, the univariate approaches of Lesion Symptom Mapping as well as Lesion Symptom Correlation mis-inferred substantial contributions from several areas even in the single-region models, and also after accounting for lesion size. By contrast, the multivariate approaches of Multi-Area Pattern Prediction, which is based on machine learning, and Multi-perturbation Shapley value Analysis, based on coalitional game theory, delivered consistently higher accuracy and specificity. Our findings suggest that the tested multivariate approaches produce largely reliable lesion inferences, without requiring lesion size consideration, while the application of the univariate methods may yield substantial mis-localizations that limit the reliability of functional attributions.