Objective: Peri‐ictal magnetic resonance imaging (MRI) abnormalities (PMA) are increasingly recognized in patients with status epilepticus (SE), but the clinical factors influencing their occurrence and extent remain incompletely understood. We aimed to quantify PMA and investigate the associations of PMA occurrence and volume with SE duration, etiology, and mortality. Methods: In this multicenter cohort study, comprising a retrospectively identified cohort and a prospectively recruited cohort, adult patients with SE who underwent brain MRI within 48 h of SE onset were included. PMA were identified on diffusion‐weighted imaging (DWI) and quantified using an automated postprocessing pipeline to calculate total PMA volume. Multivariable regression analyses were used to examine factors associated with PMA occurrence, extent, and mortality. Results: Of 260 patients, 91 (35%) had PMA on DWI. In multivariable analyses, SE duration and etiology were independently associated with PMA occurrence and volume. SE lasting >60 min had higher odds of PMA (odds ratio [OR] = 3.90, 95% confidence interval [CI] = 1.79–8.82, p < .001) and significantly greater PMA volume, whereas acute triggering factors in patients with epilepsy were linked with lower odds (OR = .15, 95% CI = .05–.44, p < .001). PMA occurrence was associated with more than threefold higher odds of mortality (adjusted OR = 3.85, 95% CI = 1.55–10.24, p = .005). Each 10‐fold increase in PMA volume was associated with 43% higher odds of mortality (adjusted OR = 1.43, 95% CI = 1.14–1.80, p = .002). In a sensitivity analysis restricted to in‐hospital mortality, each 10‐fold increase in PMA volume was associated with 47% higher odds of mortality (adjusted OR = 1.47, 95% CI = 1.15–1.89, p = .002). Significance: PMA extent is determined by SE duration and underlying etiology. Although MRI timing relative to SE termination could not always be determined, quantitative PMA assessment provides prognostic information beyond PMA presence alone, as increasing PMA volume is associated with progressively higher mortality. These findings support quantitative PMA burden as a potential imaging biomarker of SE severity and adverse outcome.

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