Introduction: The study aim is to investigate indications for breast magnetic resonance imaging (MRI) screening for high-risk women and to determine outcomes, correlation with routine imaging, and adherence to current guidelines for use. Methods: We identified 200 patients undergoing 275 breast MRIs for high-risk surveillance from 2005 to 2008. Data collected included patient characteristics, need for additional imaging and/or biopsy, correlation with routine imaging, and outcomes. Gail scores were calculated for patients without hereditary breast cancer syndromes or previous chest radiation. Descriptive statistics were utilized for data summary. Results: Two hundred patients underwent 275 breast MRIs for high-risk surveillance (mean age 45 years, range 18-76 years). Indications included BRCA mutation (n = 21), history of chest radiation (n = 10), and perceived high risk (n = 169). The mean Gail score for the latter group was 25% (range 10-46%); 32 (16%) patients had Gail score <20%. Of 275 MRIs, 49 (18%) required additional imaging and 21 (8%) prompted biopsy. Of 21 biopsies, 4 were malignant; 2 were also visible on routine imaging performed concurrently with breast MRI. The false-positive rate for breast MRI screening in our cohort of high-risk patients was 23%. Conclusion: The rate of cancer detection in high-risk patients undergoing breast MRI at our institution is similar to that of large, multicenter trials. Sixteen percent of patients undergoing breast MRI did not meet high-risk criteria. Because the need for additional imaging and biopsy remains high, further investigation is necessary to determine if this strategy is cost effective.