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We review recent MRI research that addresses two important challenges in cerebral small vessel disease (SVD) research: early diagnosis, and linking SVD with cognitive impairment. First, we review studies of MRI measurements of blood flow and blood–brain barrier integrity. Second, we review MRI studies identifying neuroimaging correlates of SVD-related cognitive dysfunction, focusing on brain connectivity and white matter microarchitecture. This research is placed in context through discussion of recent recommendations for management of incidentally discovered SVD, and neuroimaging biomarker use in clinical trials.Cerebral perfusion, cerebrovascular reactivity (CVR), blood–brain barrier permeability, and white matter microarchitecture are measurable using MRI, and are altered in SVD. Lower cerebral blood flow predicts a higher future risk for dementia, whereas decreased CVR occurs at early stages of SVD and is associated with future white matter hyperintensity growth. Two new approaches to analyzing diffusion tensor imaging (DTI) data in SVD patients have emerged: graph theory-based analysis of networks of DTI connectivity between cortical nodes, and analysis of histograms of mean diffusivity of the hemispheric white matter.New, advanced quantitative neuroimaging techniques are not ready for routine radiological practice but are already being employed as monitoring biomarkers in the newest generation of trials for SVD.