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Editor’s note: Magnetic resonance imaging (MRI) is an essential tool in diagnosing multiple sclerosis (MS) and visualizing the disease course. Acute MS lesions are hyperintense on T2 weighted images and are usually accompanied by blood–brain barrier leakage, which can be visualized by contrast enhancement. A proportion of acute T2 hyperintense lesions are simultaneously hypointense on T1 weighted images, and are termed “black holes”. When these T1 hypointensities persist, they are classed as permanent black holes. The degree of black hole formation has been suggested as a potential marker of permanent tissue damage and may correlate with the level of patient disability. Therefore, the ability to predict conversion of acute into permanent black holes may be useful, for example, as a surrogate marker in clinical trial settings.