Multimodal brain MRI abnormalities in systemic lupus erythematosus and their association with disease activity and neuropsychiatric involvement: a systematic review

OBJECTIVE: To systematically review conventional and advanced brain MRI abnormalities in systemic lupus erythematosus (SLE) and evaluate their associations with clinical features, immunological markers, and disease activity. METHODS: A systematic review was conducted according to PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420261363662). PubMed, Embase, and Web of Science were searched on August 4, 2026, covering publications through July 31, 2026. Observational studies evaluating structural and/or advanced brain MRI findings in adults with SLE were included. Demographic, clinical, immunological, and neuroimaging data were extracted, and methodological quality was assessed using Joanna Briggs Institute tools. RESULTS: One hundred eighty-eight studies were included, comprising 37 conventional and 151 advanced MRI studies. Conventional MRI abnormalities were present in over half of patients, with white matter hyperintensities and cerebral atrophy being the most frequent findings. Advanced MRI demonstrated widespread microstructural, functional, perfusion, and metabolic alterations, including reduced white matter integrity, disrupted functional connectivity, regional perfusion abnormalities, and altered cerebral metabolites. Neuroimaging abnormalities were frequently associated with disease activity, cumulative damage, cognitive impairment, and antiphospholipid antibody positivity. CONCLUSION: Brain MRI reveals diverse structural, microstructural, functional, and metabolic abnormalities associated with cerebral involvement in SLE. However, current evidence is insufficient to establish the incremental diagnostic, prognostic, or clinical management value of advanced or multimodal MRI techniques beyond conventional imaging, and prospective longitudinal studies are needed to determine their clinical utility.