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The authors evaluated 37 journal articles that included 985 patients with MS who had MR imaging in which T1-weighted postcontrast sequences were compared with noncontrast sequences obtained during the same MR imaging examination by using ROI analysis of individual MS lesions. DTI-based fractional anisotropy values were significantly different between enhancing and nonenhancing lesions, with enhancing lesions showing decreased FA. None of the other most frequently studied MR imaging biomarkers (mean diffusivity, magnetization transfer ratio, or ADC) were significantly different between enhancing and nonenhancing lesions. They conclude that noncontrast MR imaging techniques, such as DTI-based FA, can assess MS lesion acuity without gadolinium.