Structural MRI is a crucial tool in the clinical assessment of Alzheimer's disease (AD), aiding in diagnosis, progression monitoring, and treatment evaluation. Atrophy of medial temporal structures, particularly the hippocampus and entorhinal cortex, is a valid diagnostic marker at the mild cognitive impairment (MCI) stage. Structural MRI is also included in diagnostic criteria for non-AD dementias, enhancing differential diagnosis. Rates of whole-brain and hippocampal atrophy are sensitive markers of neurodegeneration and are increasingly used as outcome measures in clinical trials. Large multicenter studies are investigating other imaging and non-imaging markers to enhance diagnostic accuracy and monitoring of disease progression. Standardization of acquisition and analysis methods, along with robust automated algorithms, will improve the utility of structural imaging and other markers. The article reviews current knowledge on structural MRI changes in AD, focusing on atrophy measures and other promising biomarkers, and discusses their clinical utility and future perspectives.Structural MRI is a crucial tool in the clinical assessment of Alzheimer's disease (AD), aiding in diagnosis, progression monitoring, and treatment evaluation. Atrophy of medial temporal structures, particularly the hippocampus and entorhinal cortex, is a valid diagnostic marker at the mild cognitive impairment (MCI) stage. Structural MRI is also included in diagnostic criteria for non-AD dementias, enhancing differential diagnosis. Rates of whole-brain and hippocampal atrophy are sensitive markers of neurodegeneration and are increasingly used as outcome measures in clinical trials. Large multicenter studies are investigating other imaging and non-imaging markers to enhance diagnostic accuracy and monitoring of disease progression. Standardization of acquisition and analysis methods, along with robust automated algorithms, will improve the utility of structural imaging and other markers. The article reviews current knowledge on structural MRI changes in AD, focusing on atrophy measures and other promising biomarkers, and discusses their clinical utility and future perspectives.