JAMA neurology
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Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system traditionally characterized by an initial relapsing-remitting clinical course and focal inflammatory lesions that have a predilection for the periventricular white matter. Recently, however, histopathologic and imaging studies have illustrated a more complex pathologic substrate involving cortical demyelination, gray matter atrophy, and meningeal inflammation. Neuroimaging advances have facilitated improved detection of cortical pathology, but our understanding of the pathogenesis of cortical disease remains incomplete. The purpose of this review is to evaluate the current status and future prospects regarding the emerging role of magnetic resonance imaging to visualize leptomeningeal enhancement in patients with MS and place these findings in the proper pathobiologic and clinical context. ⋯ A growing body of evidence suggests that gray matter demyelination, cortical atrophy, and leptomeningeal inflammation may be important components of progressive MS pathology and provide a new therapeutic target. Leptomeningeal enhancement may prove a useful surrogate marker for such pathology, perhaps improving our understanding of the natural history of progressive MS, although its ultimate effect on therapeutic development and clinical care requires further study.