INTRODUCTION: Brain atrophy measurement in multiple sclerosis (MS) has become an important outcome for determining patients at risk for developing physical and cognitive disability. AREAS COVERED: In this article, we discuss the methodological issues related to using this MRI metric routinely, in a clinical setting. Understanding trajectories of annualized whole brain, gray and white matter, thalamic volume loss, and enlargement of ventricular space in specific MS phenotypes is becoming increasingly important. Evidence is mounting that disease-modifying treatments exert a positive effect on slowing brain atrophy progression in MS. Expert Commentary: While there is a need to translate measurement of brain atrophy to clinical routine at the individual patient level, there are still a number of challenges to be met before this can actually happen, including how to account for biological confounding factors and pseudoatrophy, standardize acquisition and analyses parameters, which can influence the accuracy of the assessments.

b MR Imaging Clinical Translational Research Center Jacobs School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo NY USA

Buffalo Neuroimaging Analysis Center Department of Neurology Jacobs School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo NY USA

c Department of Neurology and Center of Clinical Neuroscience Charles University Prague 1st Faculty of Medicine and General University Hospital Prague Czech Republic

e Department of Radiology 1st Faculty of Medicine and General University Hospital Charles University Prague Czech Republic

f Sydney Neuroimaging Analysis Centre; Brain and Mind Centre University of Sydney Sydney Australia

g IRCCS 'S Maria Nascente' Don Gnocchi Foundation Milan Italy

Jacobs Multiple Sclerosis Center Department of Neurology School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo NY USA

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