Prediction of improvement in speech perception after cochlear implantation (CI) is clinically important to optimize pediatric habilitation. Conventional methods using non-neural measures do not permit accurate prediction on the individual child level. In this study, we investigate whether white matter patterns detected by diffusion tensor imaging (DTI) magnetic resonance imaging (MRI) predict speech perception improvement. Pre-surgical DTI of CI candidates was compared to matched normal-hearing (NH) children to determine cortical regions affected by hearing impairment. Speech Recognition Index in Quiet was measured at baseline and 6 months post implantation to compute improvement in speech perception. Machine learning prediction of speech perception improvement (high or low) was performed using non-imaging and DTI white matter characteristics of whole, affected and unaffected brain. Affected and unaffected white matter regions were determined by comparing DTI multi-voxel pattern similarity maps of white matter integrity indices between CI and NH. Abnormal white matter patterns were found throughout brain of CI candidates. Prediction of 6-month post-CI improvement accuracy, sensitivity and specificity using unaffected regions (0.86, 0.91, 0.80, respectively) and whole brain white matter (0.85, 0.91, 0.80, respectively) yielded similar results, and were more predictive than regions affected by hearing impairment (0.72, 0.74, 0.70, respectively) or non-imaging features (0.67, 0.55, 0.78, respectively). Findings support that presurgical neural white matter pathways, especially in the association auditory and cognitive regions not affected by auditory deprivation, play a critical role in speech development after CI and are more predictive of outcome than traditional non-neural variables such as age at implant.

Nancy M Young: 1. US provisional patent application US20190192285A1 Neural predictors of language-skill outcomes in cochlear implantation patients. 2. Medical Advisory Board of Advanced Bionics, and the Surgical Advisory Board of MED-EL Corporation USA, two cochlear implant manufacturers.

National Institutes of Health R21DC016069

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics approval was obtained from the Ann & Robert H. Lurie Children's Hospital of Chicago Institution Review Board.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

All data produced in the present work are contained in the manuscript.