Advanced MRI in Multiple Sclerosis: Clinical Translation of Imaging Biomarkers in the 2024 McDonald Criteria

MRI continues to be the foundation of multiple sclerosis (MS) diagnosis and management. The latest innovations in technology have paved the way for earlier diagnosis, more informed treatment selection, better means of evaluating the disease course, and personalized therapeutic responses. This review summarizes the most recent developments in advanced MRI for MS, highlighting biomarkers that were newly added in the 2024 revisions of the McDonald criteria, describing the ongoing importance of established imaging measures, reviewing the applications of artificial intelligence in clinical practice, and suggesting future directions. Special emphasis is placed on the official adoption of the optic nerve as a fifth site of dissemination in space, as well as on the central vein sign and paramagnetic rim lesions as key supporting evidence in MS. Additionally, ongoing limitations and challenges in integrating these markers into clinical practice across both academic and community settings are identified. The overall goal is to improve diagnosis and prognostication in MS through imaging approaches that have higher contrast resolution and are more quantitative and biologically informed.