Predicting Prognosis in Primary Sclerosing Cholangitis: Conventional to Functional MRI

Primary sclerosing cholangitis (PSC) is a chronic fibroinflammatory cholangiopathy characterized by multifocal biliary strictures, cholestasis, and an increased risk of hepatobiliary malignancy and liver failure. MRI and MR cholangiopancreatography (MRCP) are central to diagnosis, surveillance, and risk stratification. Recent consensus guidelines from the International PSC Study Group emphasize standardized reporting for PSC with MRI and MRCP. Beyond anatomic assessment, established and emerging quantitative and functional imaging biomarkers include liver stiffness measurements, T1 mapping, extracellular volume fraction, and relative hepatobiliary phase enhancement. Imaging-based scoring systems such as Assessment of Noncontrast MRI for Advanced Liver Imaging (ANALI) scores provide additional prognostic information and correlate with clinical outcomes and established risk models. Hepatocyte-specific contrast-enhanced MRI allows evaluation of biliary excretion and regional liver function, facilitating identification of functional strictures and parenchymal dysfunction. The authors review current MRI and MRCP reporting standards, prognostic scoring systems, and evolving functional MRI techniques, with an emphasis on practical implementation in clinical radiology practice. ^©RSNA, 2026 See the invited commentary by Ba-Ssalamah in this issue.