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We assessed individuals with Friedreich ataxia and controls, 5 to 42\u2009years, at 7 sites across 4 continents. The 17 imaging primary outcome measures (POMs) were selected from metrics that showed a significant longitudinal change in previous small\u2010scale studies. These included brain and spinal cord morphometry (structural magnetic resonance imaging [MRI]) and microstructure (diffusion MRI); brain iron levels (quantitative susceptibility mapping); and spinal cord biochemistry (magnetic resonance spectroscopy). This study is registered with <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/clinicaltrials.gov\">ClinicalTrials.gov<\/jats:ext-link> (NCT04349514).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Between February 2021 and August 2023, we assessed 169 individuals with Friedreich ataxia and 95 controls. Compared to controls, individuals with Friedreich ataxia had lower volume of dentate nucleus and superior cerebellar peduncles; smaller cross\u2010sectional area of spinal cord; lower fractional anisotropy and higher diffusivity in spinal cord and superior cerebellar peduncles; and lower total N\u2010acetyl\u2010aspartate\/myo\u2010inositol ratio in spinal cord. Morphometric differences in spinal cord and superior cerebellar peduncles increased dramatically with age during childhood, with rapid development in controls, but not in Friedreich ataxia. Many imaging POMs showed significant associations with clinical severity.<\/jats:p><\/jats:sec><jats:sec><jats:title>Interpretation<\/jats:title><jats:p>Our findings provide strong imaging evidence of impaired development of spinal cord and superior cerebellar peduncles during childhood in Friedreich ataxia and open the way for the use of neuroimaging biomarkers in clinical trials. ANN NEUROL 2025;98:386\u2013397<\/jats:p><\/jats:sec>","DOI":"10.1002\/ana.27237","type":"journal-article","created":{"date-parts":[[2025,3,23]],"date-time":"2025-03-23T12:55:40Z","timestamp":1742734540000},"page":"386-397","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Neuroimaging Biomarkers for Friedreich Ataxia: A Cross\u2010Sectional Analysis of the <scp>TRACK<\/scp>\u2010<scp>FA<\/scp> Study"],"prefix":"10.1002","volume":"98","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0718-6760","authenticated-orcid":false,"given":"Nellie","family":"Georgiou\u2010Karistianis","sequence":"first","affiliation":[{"name":"School of Psychological Sciences, The Turner Institute for Brain and Mental Health, Monash University  Clayton Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louise A.","family":"Corben","sequence":"additional","affiliation":[{"name":"School of Psychological Sciences, The 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