MRI in multiple sclerosis: progress in in-vivo pathobiology

PURPOSE OF REVIEW: Recent advances in magnetic resonance imaging (MRI) have substantially expanded the ability to investigate multiple sclerosis (MS) pathobiology in-vivo. Beyond its diagnostic role, MRI now captures blood-brain barrier dysfunction, demyelination, neuroaxonal loss, glial activation, and network disruption across disease stages. This review is timely as accumulating evidence challenges a purely inflammation-driven ("outside-in") model of MS and supports interacting central nervous system-intrinsic ("inside-out") mechanisms that contribute to progression and disability. RECENT FINDINGS: Conventional MRI markers, such as gadolinium-enhancing lesions and T2 lesion burden, primarily reflect focal inflammatory activity. Advanced imaging techniques reveal diffuse tissue vulnerability, chronic active lesions, meningeal inflammation, metabolic dysfunction, and network failure, often independent of acute inflammation. These biomarkers bridge focal lesion pathology with smoldering, compartmentalized, and neurodegenerative processes. SUMMARY: MRI supports a unified model of MS in which inflammatory, metabolic, and neurodegenerative mechanisms interact rather than follow a single linear cascade. Mechanistic MRI biomarkers enable biological stratification of patients, inform prognosis, and provide sensitive outcome measures for neuroprotective and remyelinating therapies, moving the field beyond lesion counting toward precision medicine.