Abstract
<title>Abstract</title> <p>Background Post-stroke dysphagia (PSD) is a major stroke rehabilitation problem that impairs recovery and increases aspiration risk. The cerebellum modulates swallowing-related sensorimotor control, but whether bilateral cerebellar intermittent theta-burst stimulation (iTBS) is accompanied by whole-brain network reorganization remains unclear. Methods In this randomized, sham-controlled, assessor-blinded stroke rehabilitation trial, 64 patients with subacute PSD received bilateral cerebellar iTBS (n = 32) or sham iTBS (n = 32), each combined with conventional rehabilitation. Swallowing outcomes were assessed using the Standardized Swallowing Assessment (SSA) and Penetration-Aspiration Scale (PAS). A protocol-defined exploratory MRI substudy assessed functional connectivity, diffusion metrics, and imaging-behavior associations; MRI analyses were mechanistic and hypothesis-generating rather than confirmatory. Thirty participants were initially selected from the parent clinical cohort for MRI; after motion-related and quality-control exclusions, eight additional eligible participants were enrolled under the same protocol for the MRI substudy, resulting in 25 analyzable MRI datasets. Results Active iTBS produced greater improvement in SSA and PAS than sham stimulation. Exploratory neuroimaging identified candidate changes in cerebello-thalamo-cortical connectivity and salience network-centered interactions, especially left sensorimotor-left salience and left salience-right language network connectivity. Parcel-level signals converged within sensorimotor, salience, language, and executive-control regions. Imaging-behavior and mediation associations did not survive false discovery rate correction. Conclusions Bilateral cerebellar iTBS improved swallowing recovery in subacute PSD. MRI findings are hypothesis-generating and suggest possible involvement of cerebello-thalamo-cortical relay circuits and salience network interactions, warranting larger prospectively powered mechanistic trials.</p>