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Coenzyme Q 10 (CoQ 10 ) is an endogenously synthesized lipid molecule. It is best known for its role as a cofactor within the mitochondrial respiratory chain where it functions in electron transfer and ATP synthesis. However, there are many other cellular pathways that also depend on the CoQ 10 supply (redox homeostasis, ferroptosis and sulfide oxidation). The CoQ 10 biosynthesis pathway consists of several enzymes, which are encoded by the nuclear DNA. The majority of these enzymes are responsible for modifications of the CoQ-head group (benzoquinone ring). Only three enzymes (PDSS1, PDSS2 and COQ2) are required for assembly and attachment of the polyisoprenoid side chain. The head-modifying enzymes may assemble into resolvable domains, representing COQ complexes. During the last two decades, numerous inborn errors in CoQ 10 biosynthesis enzymes have been identified. Thus far, 11 disease genes are known ( PDSS1 , PDSS2 , COQ2 , COQ4 , COQ5 , COQ6 , COQ7 , COQ8A , COQ8B , COQ9 and HPDL ). Disease onset is highly variable and ranges from the neonatal period to late adulthood. CoQ 10 deficiency exerts detrimental effects on the nervous system. Potential consequences are neuronal death, neuroinflammation and cerebral gliosis. Clinical features include encephalopathy, regression, movement disorders, epilepsy and intellectual disability. Brain magnetic resonance imaging (MRI) is the most important tool for diagnostic evaluation of neurological damage in individuals with CoQ 10 deficiency. However, due to the rarity of the different gene defects, information on disease manifestations within the central nervous system is scarce. This review aims to provide an overview of brain MRI patterns observed in primary CoQ 10 biosynthesis disorders and to highlight disease-specific findings.