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In Journal of Neurology, Neurosurgery and Psychiatry, Muraro et al 1 and Mariottini et al 2 provide real-world perspectives on the role of autologous haematopoietic stem cell transplantation (AHSCT) in multiple sclerosis (MS). AHSCT has potent and durable efficacy for patients with aggressive forms of MS. Historically, AHSCT was viewed as a rescue option for advanced, treatment-refractory MS. In recent years, accumulating evidence from observational studies, phase 2 trials, and randomised clinical trials (RCTs) has consistently demonstrated the superiority of AHSCT in relapse prevention, MRI activity reduction and disability progression when compared with high-efficacy disease-modifying therapies (HE-DMT).3 4 Consequently, AHSCT is increasingly regarded as a second-line treatment for patients who have failed one HE-DMT.5 Nevertheless, critical questions remain regarding optimal patient selection, as well as long-term efficacy and safety when compared with HE-DMT.