Purpose <p>Evaluate the clinical outcomes of MRI studies in suspected pediatric appendicitis which have been read as equivocal. Propose a 5-component scoring system to further increase the diagnostic accuracy of MRI.</p> Methods <p>A retrospective review of pediatric patients referred for MRI from January 2017 to April 2020 was conducted. All patients were initially evaluated with US. MRI studies were classified as positive, negative, or equivocal by attending pediatric radiologists. A novel 5-component scoring system was applied to classify MRI findings, with scores based on five imaging features. The study analyzed the diagnostic performance of the scoring system with age and gender matched controls and compared the same with the entire cohort.</p> Results <p>Out of 615 MRI studies, 432 (70.2%) were negative, 139 (22.6%) positive, and 44 (7.2%) equivocal. The 5-component score system demonstrated significant differences in key imaging components (appendiceal diameter, wall thickening, peri-appendiceal fluid, inflammation, and appendicolith presence) between positive and negative cases. Among equivocal cases, 13.6% were ultimately diagnosed with appendicitis, with higher rates of IV contrast administration in equivocal studies (75%). Total scores of 3 to 5 had an AUC value of 0.87 for equivocals and 0.97 for the entire cohort indicating moderate to high diagnostic accuracies.</p> Conclusions <p>MRI is a valuable tool in diagnosing pediatric appendicitis and the introduction of a 5-component scoring system can aid in interpreting equivocal MRI findings and guide clinical decision-making. The proposed scoring system could enhance diagnostic accuracy and better classify equivocal cases in children and adolescents suspected of having appendicitis.</p> Graphical abstract <p></p>