Treatment Effects on Chronic Active Lesions in Multiple Sclerosis: Current Evidence and Future Perspectives

INTRODUCTION: Multiple sclerosis (MS) is characterized by chronic, compartmentalized inflammation persisting behind a relatively intact blood-brain barrier. This process can be assessed in vivo using neuroimaging biomarkers of chronic active lesions (CALs): paramagnetic rim lesions (PRLs), slowly expanding lesions (SELs), and lesions showing increased uptake of 18-kDa translocator protein (TSPO) positron emission tomography (PET) tracers. Given their association with more severe structural damage, clinical disability, and disease progression, CALs represent a biologically relevant target to assess whether disease-modifying therapies (DMTs) can modulate smoldering MS pathology. METHODS: This narrative review summarizes current evidence on the effects of DMTs on CAL-associated imaging biomarkers and discusses implications for future clinical trial design targeting smoldering MS biology. RESULTS: Despite their strong biological and clinical relevance, current evidence suggests that available DMTs have a limited and inconsistent effect on CAL occurrence and evolution over short- to medium-term follow-up. However, treatment effects may be more apparent at the microstructural level, potentially attenuating intralesional progressive microstructural damage accumulation. Interpretation of existing data is challenged by heterogeneous MS cohorts, variability in imaging methodologies, short follow-up durations, and the only partial biological overlap among PRLs, SELs, and TSPO-PET lesions, which capture distinct dimensions of chronic inflammatory activity. CONCLUSIONS: Future studies should include prospective, multimodal longitudinal designs with standardized imaging protocols and CAL-specific endpoints to better define treatment effects on compartmentalized inflammation.