Introduction: Metabolic dysfunction-associated steatohepatitis (MASH) is an advanced form of metabolic dysfunction-associated steatotic liver disease (MASLD), characterised by hepatocellular injury, inflammation and varying degrees of fibrosis. Non-invasive, accurate diagnostic tools are critical for identifying patients “at risk” (MAS ≥4, F ≥2). This meta-analysis evaluates the diagnostic performance of imaging-based technologies for ruling in (TRI) and ruling out (TRO) “at risk” MASH. Methods: A systematic search of Medline and Embase (inception to December 20, 2024) identified studies reporting on MRI-based diagnostic techniques for “at risk” MASH. Eligible studies were independently screened, with 20 studies meeting inclusion criteria. Sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated using bivariate meta-analysis, applying pre-specified TRO and TRI thresholds to each technique. Results: Twenty studies involving 9,480 participants were included. FAST demonstrated highest TRO sensitivity (0.871) with moderate specificity (0.567) and TRI specificity (0.900) with reduced sensitivity (0.441). MEFIB achieved high TRO sensitivity (0.812) but lower specificity (0.606); TRI specificity was 0.872, sensitivity was 0.500. MAST exhibited intermediate performance, while cT1 thresholds showed variable diagnostic accuracy. A sensitivity analysis of head-to-head studies shows superior performance in FAST compared to other diagnostic methods. Conclusion: FAST with its accessibility and robust diagnostic performance may be well-suited for large-scale application. MRI-based techniques are effective non-invasive options for diagnosing “at risk” MASH in MASLD and may provide strong alternatives. Rather than challenging existing perspectives, this study provides a reflective overview of current evidence on imaging-based modalities for “at risk” MASH.