MRI risk stratification in metabolic dysfunction–associated steatotic liver disease (MASLD): from diffuse liver disease to focal lesions

Abstract

Metabolic dysfunction–associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide. Hepatic steatosis, its imaging hallmark, is a frequent incidental finding in abdominal imaging, often prompting further clinical evaluation. Despite this, the integration of imaging-derived biomarkers into structured risk stratification pathways and longitudinal disease management remains inconsistent in clinical practice. This narrative review outlines the role of multiparametric magnetic resonance imaging (MRI) in the assessment of MASLD, focusing on clinically actionable applications for abdominal radiology. Quantitative MRI biomarkers — including proton density fat fraction (MRI-PDFF), magnetic resonance elastography (MRE), R2* iron quantification, and gadoxetic acid–enhanced MRI — provide complementary information for evaluation of steatosis, fibrosis, iron overload, hepatocellular function, and focal liver lesions. The contribution of multiparametric MRI to opportunistic disease detection, identification of clinically significant fibrosis, and longitudinal monitoring of disease progression and therapeutic response is summarized. Key imaging pitfalls in steatotic livers are addressed, including altered lesion conspicuity, heterogeneous fat and stiffness distribution, focal stiffness abnormalities, and diagnostic challenges related to hepatocellular carcinoma in non-cirrhotic MASLD. Multiparametric MRI enables comprehensive, noninvasive, whole-liver evaluation of MASLD and supports imaging-informed risk stratification and longitudinal disease management in abdominal radiology practice.