Conventional and Emerging MRI Biomarkers of Multiple Sclerosis

MRI plays a central role in the diagnosis and management of multiple sclerosis (MS), and the 2017 revised McDonald criteria have improved the sensitivity and accuracy for early diagnosis. While these criteria have been validated and improve patient outcomes, the improper application of these practice standards-especially in cases of atypical presentations-can lead to misdiagnosis. To enhance diagnostic specificity, emerging MRI biomarkers such as the central vein sign and paramagnetic rim lesions are now incorporated into the 2024 revised McDonald criteria. These biomarkers show promise for differentiating MS from mimicking conditions. Additional emerging techniques, including artificial intelligence-driven analysis, also have the potential to refine diagnostic clinical workflows by capturing subtle imaging features that are beyond human perception. Accurate interpretation of these MRI features is essential to maintaining diagnostic accuracy across clinical settings. This review highlights conventional and emerging MRI biomarkers for MS diagnosis, highlighting the diagnostic and prognostic utilities of and underlying pathophysiologic processes behind these imaging findings.