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The authors tested the hypothesis that recently introduced 4D dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism. Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease—9 with double-gland hyperplasia; 3 with 3-gland hyperplasia, and 5 with 4-gland hyperplasia. For single-gland disease, the gland was correctly located in 92% of patients, with correct identification of the side in 100% and the quadrant in 92%. For multigland disease, the glands were correctly located in 74% of patients, with correct identification of the side in 74% and the quadrant in 77%. The high spatial and temporal resolution 4D dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism.