Hypomyelinating leukodystrophies represent a genetically heterogeneous but clinically overlapping group of heritable disorders. Current management approaches in the care of the patient with a hypomyelinating leukodystrophy include use of serial magnetic resonance imaging (MRI) to establish and monitor hypomyelination, molecular diagnostics to determine a specific etiology, and equally importantly, careful attention to neurologic complications over time. Emerging research in oligodendrocyte biology and neuroradiology with bedside applications may result in the possibility of clinical trials in the near term, yet there are significant gaps in knowledge in disease classification, characterization, and outcome measures in this group of disorders. Here we review the biological background of myelination, the clinical and genetic variability in hypomyelinating leukodystrophies, and the insights that can be obtained from current MRI techniques. In addition, we discuss ongoing research approaches to define potential outcome markers for future clinical trials. ANN NEUROL 2014;76:5-19 T he concept of hypomyelinating disorders was originated by Schiffmann, van der Knaap, and colleagues.1-3 Among the inherited white matter (WM) disorders, hypomyelinating leukodystrophies (HLDs) are notable for abnormalities in myelin development rather than destruction. This class of disorders is distinguished by their characteristic appearance on magnetic resonance imaging (MRI), namely, lessening or absence of the T 2 hypointensity that typically signifies the presence of myelin, often without the significant lessening of T 1 hyperintensity seen in the other, nonhypomyelinating leukodystrophies. Other MRI features help to narrow the differential diagnosis and focus genetic and metabolic testing. 3 We are entering a phase of clinical research for HLDs where identification of outcome measures of potential treatment benefit is crucial. In ultrarare diseases, clinical features, and natural history are often This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. poorly known; therefore, clinical/neurological parameters alone are insufficient as endpoints for clinical efficacy studies. In this case, another possible acceptable clinical trial design includes the use of biomarkers as surrogate endpoints. The adoption of criteria for biomarkers of efficacy is an important feasibility step for the planning and execution of clinical studies because it provides an objective endpoint at a defined period of time after an intervention has been initiated. Proposing a standard measure of myelination based upon magnetic resonance (MR) metrics as a reliable biomarker could therefore greatly encourage clinical research.With these challenges in mind, we organized a multidisciplinary group to address clinical and future research priorities for HLDs. The group ...