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Review
. 2025 Oct;24(10):866-879.
doi: 10.1016/S1474-4422(25)00304-7.

2024 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI for the diagnosis of multiple sclerosis

Affiliations
Review

2024 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI for the diagnosis of multiple sclerosis

Frederik Barkhof et al. Lancet Neurol. 2025 Oct.

Abstract

MRI plays an increasingly important role in the diagnosis of multiple sclerosis. We discuss the expanded role of MRI in the 2024 McDonald diagnostic criteria for multiple sclerosis, which include the optic nerve as a fifth anatomical location, in addition to the periventricular, juxtacortical or cortical, infratentorial, and spinal cord regions. The diagnosis of multiple sclerosis can now be confirmed when the criteria of dissemination in space are fulfilled with the detection of typical lesions in at least four locations without additional evidence. We recommend appropriate imaging strategies and MRI acquisition protocols for all aspects of multiple sclerosis diagnosis, including fat-saturated sequences for detection of symptomatic optic nerve lesions. Diagnostic imaging should always cover the brain and spinal cord and include susceptibility-sensitive sequences for the assessment of the central vein sign and paramagnetic rim lesions, which can be especially helpful in cases when conventional imaging findings are insufficient to establish a diagnosis. We discuss how to handle the diagnosis of radiologically isolated presentations of multiple sclerosis, which are included in the 2024 criteria. We present recommendations for image interpretation and avoidance of misdiagnosis, and extend the recommendations to the use of MRI in the diagnosis of multiple sclerosis in older people, children, people with vascular comorbidities or migraine, and people living outside Europe and North America. Finally, we provide recommendations for standardisation of MRI acquisition and communication of results to enable an earlier diagnosis while maintaining high diagnostic specificity.

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Conflict of interest statement

Declaration of interests FBar is supported by European Commission, Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals, GE Healthcare, Roche, and Alzheimer's Disease Data Initiative (paid to institution); is a consultant for Combinostics, IXICO, and Roche; and participates in Steering Committees or Data safety Monitoring Boards for EISAI, Biogen, Prothena, and Merck. DSR is supported by the Intramural Research Program of the National Institute of Neurological Disorders and Stroke, US National Institutes of Health (NIH); and he has received research support from Abata Therapeutics and Sanofi. JO holds the Waugh Family Chair in MS Research at St Michael's Hospital, University of Toronto; has received grant funding from MS Canada, Brain Canada, the National MS Society, Biogen-Idec, Roche, and EMD-Serono; and has received personal compensation for consulting or speaking from Biogen-Idec, BMS, EMD-Serono, Eli Lilly, Horizon Therapeutics, Novartis, Roche, and Sanofi-Genzyme. MAR received consulting fees from Biogen, Bristol Myers Squibb, Eli Lilly, Janssen, and Roche; received speaker honoraria from Astra-Zeneca, Biogen, Bristol Myers Squibb, Bromatech, Celgene, Genzyme, Horizon Therapeutics Italy, Merck Serono SpA, Novartis, Roche, Sanofi, and Teva; and declares research support from the MS Society of Canada, the Italian Ministry of Health, the Italian Ministry of University and Research, and Fondazione Italiana Sclerosi Multipla. DKBL is Emeritus Director of the UBC MS/MRI Research Group, which has received grant support for investigator-initiated studies from Genzyme and Roche; and has given lectures, supported by non-restricted education grants from Academy of Health Care Learning, Biogen, Novartis, Consortium of MS Centers, and Sanofi-Genzyme. PS receives research support from the National Institutes of Health, the National Multiple Sclerosis Society, the Department of Defense, and the Erwin Rautenberg Foundation. CJA receives grant support from the National MS Society, the National Institutes of Health, and the Keck School of Medicine; has received consulting honoraria for participation in advisory boards, data safety monitoring committee from MRI Adjudication Committee for Horizon Therapeutics, TG Therapeutics, EMD Serono, Genentech, and Zenas Biopharma; and for participation in educational events for Sanofi Genzyme, MJH Life Sciences, Efficient, and Spire Learning. FBag is supported by the National Institute of Health, The VA Healthcare Administration, the National MS Society and the Voros Innovation and Impact Funds; is a consultant for Sanofi; and participates in Steering Committee and Advisory Boards for Merck-Serono and Sanofi. PAC has received grant funding from the NIH, National Multiple Sclerosis Society, US Department of Defense, Genentech, and the Myelin Repair Foundation; and has received consulting honoraria for serving on scientific advisory boards for Novartis, Idorsia, and Elli Lilly. OC has received grant funding from National Institute for Health and Care Research, UK MS Society, Medical Research Council, and Rosetrees Trust; and has received personal compensation for consulting or speaking from Novartis, Roche, and Biogen. MGD received grant support from Novartis, Bristol Myers Squibb, Mapi Pharma, and Merck Serono; and declares consulting fees from Bristol Myers Squibb and Mapi Pharma. GCD has received research funding from the Oxford Biomedical Research Centre, Medical Research Council (UK), National Health and Medical Research Council, UK MS Society, Department of Defense, Oxford-Quinnipiac-Trinity Health Of New England Partnership, Rosetrees Trust, and the Multiple sclerosis Research, Treatment, and Education; and has received honoraria for consulting or speaking for Novartis, Merck, the MS Academy, American Academy of Neurology, and the Wellcome Trust. NDS has received honoraria from Biogen, Celgene (Bristol Myers Squibb), EMD Serono, Genzyme, Immunic, Novartis, Roche, and Teva for consulting services, speaking, and travel support; serves on advisory boards for Biogen, Genzyme, Immunic (the healthcare business of Merck), Darmstadt, Germany, Novartis, and Roche; has received research grant support from the Italian MS Society; and is co-founder of Siena Imaging. CE has received funding for travel and speaker honoraria from Biogen, Bayer, Celgene, Merck, Novartis, Roche, Shire, Genzyme and Teva Pharmaceutical Industries/Sanofi-Aventis; received research support from Merck Serono, Biogen, and Teva Pharmaceutical Industries/Aanofi-Aventis; and has served on scientific advisory boards for Bayer, Biogen, Celgene, Merck, Novartis, Roche, and Teva Pharmaceutical Industries/Sanofi-Aventis. MF received compensation for consulting services from Alexion, Almirall, Biogen, Merck, Novartis, Roche, and Sanofi; declares speaking activities from Bayer, Biogen, Celgene, Chiesi Italia SpA, Eli Lilly, Genzyme, Janssen, Merck-Serono, Neopharmed Gentili, Novartis, Novo Nordisk, Roche, Sanofi, Takeda, and TEVA; participation in Advisory Boards for Alexion, Biogen, Bristol-Myers Squibb, Merck, Novartis, Roche, Sanofi, Sanofi-Aventis, Sanofi-Genzyme, and Takeda; scientific direction of educational events for Biogen, Merck, Roche, Celgene, Bristol-Myers Squibb, Lilly, Novartis, and Sanofi-Genzyme; and receives research support from Biogen, Merck-Serono, Novartis, Roche, the Italian Ministry of Health, the Italian Ministry of University and Research, and Fondazione Italiana Sclerosi Multipla. CGo is supported by the Swiss National Science Foundationgrant (PP00P3_176984), the Stiftung zur Förderung der gastroenterologischen und allgemeinen klinischen Forschung, University Hospital Basel, and the Research Center for Clinical neuroimmunology and Neuroscience; the employers of Cristina Granziera have received the fees (used exclusively for research support) from Siemens, GeNeuro, Genzyme-Sanofi, Biogen, Novartis, and Hoffmann La Roche; the employers of Cristina Granziera also have received advisory board and consultancy fees from Actelion, Genzyme-Sanofi, Novartis, GeNeuro, Merck, Biogen, and Hoffmann La Roche, as well as speaker fees from Genzyme-Sanofi, Novartis, GeNeuro, Merck, Biogen, and Hoffmann La Roche. RGH has received consulting fees from Roche, Novartis, QIA Consulting, Sanofi, and Boston Pharma; and research funding from Roche, Genentech, and Atara. CGa has received fees as a speaker or as an advisory board member from Almirall, Biogen, Merck, Roche, Novartis, Sandoz, AstraZeneca, Viatris, Sanofi, Jansen, and Bristol Myers Squibb. SG has received grant funding from the National Institutes of Health, National Multiple Sclerosis Society, and Genentech; and has received consulting fees from Contineum Therapeutics and Kiniksa Pharmaceuticals. LK received research support to the institution (University Hospital Basel, Basel, Switzerland) including steering committee, advisory board, and consultancy fees from Actelion (Janssen), Bayer, Biogen, Bristol Myers Squibb, GSK, Janssen, Japan Tobacco, Merck, Novartis, Roche, Sanofi, Santhera, and Shionogi, and TG Therapeutics; speaker fees from Bayer, Biogen, Merck, Novartis, Roche, and Sanofi; support of educational activities from Allergan, Bayer, Biogen, CSL Behring, Desitin, Merck, Novartis, Pfizer, Roche, Sanofi, Shire, and Teva; license fees for Neurostatus platform access; and grants from Bayer, Biogen, EU, InnoSwiss, Merck, Novartis, Roche, Swiss Multiple Sclerosis Society, and Swiss National Research Foundation. CL reports funding support from the Natural Sciences and Engineering Research Council of Canada, the Craig H. Neilsen Foundation, the International Collaboration on Repair Discoveries, and the University of British Columbia. SDN reports grants or contracts from Biogen, Roche, Genentech, Lunbeck, Sanofi, National Multiple Sclerosis Society, Department of Defense, and Patient Centered Outcomes Research Institute; personal compensation for consulting from Biogen, Roche, Genentech, Bristol Myers Squibb, Novartis, and TG Therapeutics; is the study lead PI for a Roche clinical trial program; and reports research support from the Stiff Person Syndrome Research Foundation. XM's institution has received compensation for lecture honoraria and travel expenses, participation in scientific meetings, clinical trial steering committee membership, or clinical advisory board participation in recent years from Abbvie, Actelion, Alexion, Bial PD, Biogen, Bristol-Myers Squibb/Celgene, EMD Serono, Genzyme, Hoffmann-La Roche, Immunic Therapeutics, Janssen Pharmaceuticals, Medday, Merck, Mylan, Nervgen, Neuraxpharm, Novartis, Peervoice, Samsung-Biosys, Sandoz, Sanofi-Genzyme, Teva Pharmaceutical, TG Therapeutics, Excemed, Medscape, European Committee for Treatment and Research in Multiple Sclerosis, Multiple Sclerosis International Federation, and National Multiple Sclerosis Society or any of their affiliates. In the last 3 years, SAM has served as an advisory board member or received consulting fees from Biogen Idec, BMS/Celgene, EMD Serono, Novartis, Roche, and Sanofi Genzyme; participated in a speaker's bureau for Biogen Idec, BMS/Celgene, EMD Serono, Novartis, Roche, and Sanofi; has received research support from Biogen Idec EMD Serono, Novartis, Roche, Sanofi Genzyme, MS Canada, Canadian Institute of Health Research, and National Multiple Sclerosis Society; has participated as a site investigator in clinical trials sponsored by BMS/Celgene, EMD Serono, Novartis, Roche, and Sanofi; and has acted as site PI for multi-center trials funded by BMS/Celgene, EMD Serono, Novartis, Roche, and Sanofi Genzyme. MMS serves on the editorial board of Neurology, Multiple Sclerosis Journal, and Frontiers in Neurology; receives research support from the Dutch MS Research Foundation, Eurostars-EUREKA, Association pur la Recherche sur la Sclerose en Plaque, Amsterdam Neuroscience, MAGNIMS, and ZonMW (Vidi grant, project number 09150172010056); and has served as a consultant for or received research support from Atara Biotherapeutics, Biogen, Celgene/Bristol Meyers Squibb, EIP, Sanofi, MedDay, and Merck. NS receives research funding from the NIH, National MS Society, and Patient Centered Outcomes Research Institute. ATo has been supported by recent grants from the Medical Research Council (MR/S026088/1National Institute for Health and Care Research Biomedical Research Centre (541/CAP/OC/818837), and RoseTrees Trust (A1332 and PGL21/10079); speaker honoraria from Merck, Biomedia, Sereno Symposia International Foundation, Bayer, and At the Limits; was reimbursed for meeting expenses from Merck, Biogen Idec, and Novartis; and was the UK PI for two clinical trials sponsored by MEDDAY pharmaceutical company (MD1003 in optic neuropathy [MS-ON - NCT02220244] and progressive MS [MS-SPI2 - NCT02936037]). JW has research support from Biogen; is a consultant for BMS; and has been a speaker for Biogen, EMD Serono, and Sanofi. JS-G received compensation in the last 24 months for consulting services and speaking honoraria from BMS, Sanofi, Merck, and Roche; is scientific director of Revista de Neurología and member of the editorial committee of Multiple Sclerosis Journal, for which he receives an honorarium; and he has received research support from Fondo de Investigación en Salud (PI19/00950 and PI22/00750) from Instituto de Salud Carlos III, Spain. ATr is the MS Canada Research Chair; has received honoraria from Sanofi for membership in data monitoring committee and clinical trial steering committee and from Roche for clinical trial steering committee membership; and declares research funding from Roche, NIH, and MS Society of Canada. DO has received research support from the National Institutes of Health, National Multiple Sclerosis Society, Patient Centered Outcomes Research Institute, Race to Erase MS Foundation, Genentech, Genzyme, Bristol Myers Squibb, and Novartis; and declares consulting fees from Bristol Myers Squibb, Genentech/Roche, Novartis, and Contineum Therapeutics. AR serves on scientific advisory boards for Novartis, Sanofi, Synthetic MR, Roche, and Biogen; has received speaker honoraria from Bayer, Sanofi-Genzyme, Merck-Serono, Teva Pharmaceutical Industries, Novartis, Roche, Bristol-Myers and Biogen; is the CMO and co-founder of TensorMedical; and receives research support from Fondo de Investigación en Salud (PI19/00950 and PI22/01589) from Instituto de Salud Carlos III, Spain. All other authors declare no competing interests.

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