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This chapter describes the specific magnetic resonance imaging (MRI) features of pediatric multiple sclerosis (MS). It also discusses proposed MRI criteria for pediatric MS and compares these to the MRI diagnostic criteria well established for adult patients who present with a first demyelinating event. MRI studies in children help to understand early pathogenic events that lead to clinical symptoms and signs of MS. MRI detects white matter pathology that represents clinically silent demyelination in adults. The absence of brain or spine lesions on the initial MRI study seems to be associated with very low risk of progression to MS. Studies in adult MS patients have shown that the initial lesion burden on brain imaging may be an important prognostic factor. The MRI criteria for acute disseminated encephalomyelitis (ADEM) include the presence of poorly defined lesions and a high lesion load, associated with thalamus and basal ganglia involvement.