To investigate whether and how the COVID-19 pandemic has changed medical imaging trends by synthesizing the highly cited studies before and during the pandemic. In this cross-sectional study, we identified highly cited studies on medical imaging from the essential science indicators (ESI) database, categorizing them into two periods: before the pandemic (January 2016-December 2019) and during the pandemic (January 2020-December 2023). We conducted a global research landscape comparative analysis and utilized CiteSpace and VOSviewer software to create knowledge maps for analyzing the co-occurrences of keywords and references in this field. A total of 2914 highly cited studies were included in this study, which revealed a notable 30.1% increase in medical imaging publications during the pandemic. Enhanced international cooperation has been observed, with European countries and the US leading the research efforts. Keyword analysis revealed that artificial intelligence (AI) has remained a dominant hotspot in medical imaging research before and during the pandemic. References analysis showed a shift in focus towards COVID-19-related studies, overshadowing some important areas including cancer imaging, cardiac imaging, and neuroimaging. Over the past four years, the COVID-19 pandemic has led to changes in the research output, international collaborations, and hotspots within highly cited medical imaging studies. Navigating the post-COVID era, it is imperative to continue fostering international collaboration, prioritize resource allocation to refocus on overlooked research areas, and develop long-term strategic plans to prepare for and mitigate the impact of future public health crises. Question Understanding how the COVID-19 pandemic has changed medical imaging trends and priorities, which is crucial for preparing against future public health crises, remains unclear. Findings The COVID-19 pandemic has led to increases in highly cited medical imaging studies, enhancements in international collaborations, and shifts in research hotspots. Clinical relevance This study provides a comprehensive overview of highly cited studies on medical imaging before and during the pandemic, highlighting the pivotal role of AI in the post-COVID era and emphasizing the need to refocus on potentially neglected research areas.