Objective: This article discusses the use of novel and emerging neuroimaging biomarkers to facilitate the diagnosis of multiple sclerosis (MS) in clinical practice.

Latest developments: MRI measures have played an increasingly important role in the evolution of the MS diagnostic criteria. Revisions of these criteria in 2017 and 2024 included novel MRI biomarkers, including cortical lesions, the central vein sign, and paramagnetic rim lesions.

Essential points: Although not required to diagnose MS, the central vein sign, paramagnetic rim lesions, and cortical lesions are novel imaging diagnostic biomarkers that are useful for diagnosing MS in specific situations, including in people presenting with typical clinical symptoms but not meeting criteria for dissemination in space or time, and atypical clinical presentations. Cortical lesions can be detected with appropriate MRI sequences, and, together with juxtacortical lesions, constitute a typical topography that fulfills the requirements for dissemination in space in MS diagnostic criteria. Susceptibility-based sequences are suitable for visualizing the central vein sign and paramagnetic rim lesions, which can be useful in facilitating a diagnosis of MS in specific situations. All of these novel MRI measures are highly specific for MS and can increase the sensitivity of MS diagnosis, thereby facilitating the diagnosis of MS in individuals early on in the disease course, while preventing misdiagnosis.