Background <p>Stroke often leads to motor disabilities, and effective rehabilitation is crucial for restoring limb function. Gamified rehabilitation programs have emerged to increase stroke survivor motivation through engaging environments and rewards. However, it is uncertain whether stroke survivors respond to video game environments and challenges in the same way as healthy individuals do, given the potential impact of stroke on mood and intrinsic motivation.</p> Methods <p>EEG data were collected from stroke survivors and healthy controls under multiple conditions. Initially, a cognitively activated state was identified via an N-back task. The participants subsequently engaged with an upper limb rehabilitation game featuring an immersive 3D environment. The brain activity patterns during this engaging game were then compared to those during a version of the same task without a 3D, gamified environment. Finally, responses to a more challenging iteration of the engaging game were assessed.</p> Results <p>While healthy controls showed brain activity indicative of effort and attention in N-back and subsequent games, stroke survivors displayed similar brain activation patterns only when playing the engaging version of the game. Notably, increasing the game difficulty increased attentional states in controls but not in stroke survivors.</p> Conclusions <p>Our findings suggest that an engagement mental state, as indexed by EEG markers, is more difficult to achieve in stroke survivors during repetitive tasks than in healthy controls. However, engaging in video game environments can significantly increase stroke survivors’ motivation and participation, provided that the difficulty level is appropriately adjusted. We believe this provides evidence that video game-based rehabilitation is a promising approach to promote stroke survivor engagement through enhanced motivation.</p>