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Li W, Li H, Lu C, Zhao J, Xu H, Xu Z, Mitchell B, Jiang Y, Gu HQ, Xu Q, Wang A, Meng X, Lin J, Jing J, Li Z, Zhu W, Liang Z, Wang M, Wang Y. Neglected Mendelian causes of stroke in adult Chinese patients who had an ischaemic stroke or transient ischaemic attack. Stroke Vasc Neurol 2024; 9:194-201. [PMID: 37495379 PMCID: PMC11221298 DOI: 10.1136/svn-2022-002158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 06/27/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Multiple factors play important roles in the occurrence and prognosis of stroke. However, the roles of monogenic variants in all-cause ischaemic stroke have not been systematically investigated. We aim to identify underdiagnosed monogenic stroke in an adult ischaemic stroke/transient ischaemic attack (TIA) cohort (the Third China National Stroke Registry, CNSR-III). METHODS Targeted next-generation sequencing for 181 genes associated with stroke was conducted on DNA samples from 10 428 patients recruited through CNSR-III. The genetic and clinical data from electronic health records (EHRs) were reviewed for completion of the diagnostic process. We assessed the percentages of individuals with pathogenic or likely pathogenic (P/LP) variants, and the diagnostic yield of pathogenic variants in known monogenic disease genes with associated phenotypes. RESULTS In total, 1953 individuals harboured at least one P/LP variant out of 10 428 patients. Then, 792 (7.6%) individuals (comprising 759 individuals harbouring one P/LP variant in one gene, 29 individuals harbouring two or more P/LP variants in different genes and 4 individuals with two P/LP variants in ABCC6) were predicted to be at risk for one or more monogenic diseases based on the inheritance pattern. Finally, 230 of 792 individuals manifested a clinical phenotype in the EHR data to support the diagnosis of stroke with a monogenic cause. The most diagnosed Mendelian cause of stroke in the cohort was cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. There were no relationships between age or family history and the incidence of first symptomatic monogenic stroke in patients. CONCLUSION The rate of monogenic cause of stroke was 2.2% after reviewing the clinical phenotype. Possible reasons that Mendelian causes of stroke may be missed in adult patients who had an ischaemic stroke/TIA include a late onset of stroke symptoms, combination with common vascular risks and the absence of a prominent family history.
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Affiliation(s)
- Wei Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chaoxia Lu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jialu Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huichun Xu
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zhe Xu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Braxton Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wanlin Zhu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhigang Liang
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Clinical Center for Precision Medicine in Stroke, Capital Medical University, Beijing, China
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Cerfontaine MN, Hack RJ, Gesierich B, Duering M, Witjes-Ané MNW, Rodríguez-Girondo M, Gravesteijn G, Rutten J, Lesnik Oberstein SAJ. Association of NOTCH3 Variant Risk Category With 2-Year Clinical and Radiologic Small Vessel Disease Progression in Patients With CADASIL. Neurology 2024; 102:e209310. [PMID: 38713890 PMCID: PMC11177591 DOI: 10.1212/wnl.0000000000209310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/01/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pathogenic variants in NOTCH3 are the main cause of hereditary cerebral small vessel disease (SVD). SVD-associated NOTCH3 variants have recently been categorized into high risk (HR), moderate risk (MR), or low risk (LR) for developing early-onset severe SVD. The most severe NOTCH3-associated SVD phenotype is also known as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We aimed to investigate whether NOTCH3 variant risk category is associated with 2-year progression rate of SVD clinical and neuroimaging outcomes in CADASIL. METHODS A single-center prospective 2-year follow-up study was performed of patients with CADASIL. Clinical outcomes were incident stroke, disability (modified Rankin Scale), and executive function (Trail Making Test B given A t-scores). Neuroimaging outcomes were mean skeletonized mean diffusivity (MSMD), normalized white matter hyperintensity volume (nWMHv), normalized lacune volume (nLV), and brain parenchymal fraction (BPF). Cox regression and mixed-effect models, adjusted for age, sex, and cardiovascular risk factors, were used to study 2-year changes in outcomes and differences in disease progression between patients with HR-NOTCH3 and MR-NOTCH3 variants. RESULTS One hundred sixty-two patients with HR (n = 90), MR (n = 67), and LR (n = 5) NOTCH3 variants were included. For the entire cohort, there was 2-year mean progression for MSMD (β = 0.20, 95% CI 0.17-0.23, p = 7.0 × 10-24), nLV (β = 0.13, 95% CI 0.080-0.19, p = 2.1 × 10-6), nWMHv (β = 0.092, 95% CI 0.075-0.11, p = 8.8 × 10-20), and BPF (β = -0.22, 95% CI -0.26 to -0.19, p = 3.2 × 10-22), as well as an increase in disability (p = 0.002) and decline of executive function (β = -0.15, 95% CI -0.30 to -3.4 × 10-5, p = 0.05). The HR-NOTCH3 group had a higher probability of 2-year incident stroke (hazard ratio 4.3, 95% CI 1.4-13.5, p = 0.011), and a higher increase in MSMD (β = 0.074, 95% CI 0.013-0.14, p = 0.017) and nLV (β = 0.14, 95% CI 0.034-0.24, p = 0.0089) than the MR-NOTCH3 group. Subgroup analyses showed significant 2-year progression of MSMD in young (n = 17, β = 0.014, 95% CI 0.0093-0.019, p = 1.4 × 10-5) and premanifest (n = 24, β = 0.012, 95% CI 0.0082-0.016, p = 1.1 × 10-6) individuals. DISCUSSION In a trial-sensitive time span of 2 years, we found that patients with HR-NOTCH3 variants have a significantly faster progression of major clinical and neuroimaging outcomes, compared with patients with MR-NOTCH3 variants. This has important implications for clinical trial design and disease prediction and monitoring in the clinic. Moreover, we show that MSMD is a promising outcome measure for trials enrolling premanifest individuals.
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Affiliation(s)
- Minne N Cerfontaine
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Remco J Hack
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Benno Gesierich
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Marco Duering
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Marie-Noëlle W Witjes-Ané
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Mar Rodríguez-Girondo
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Gido Gravesteijn
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Julie Rutten
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
| | - Saskia A J Lesnik Oberstein
- From the Departments of Clinical Genetics (M.N.C., R.J.H., G.G., J.R., S.A.J.L.O.), Geriatrics and Psychiatrics (M.-N.W.W.-A.), and Medical Statistics (M.R.-G.), Leiden University Medical Center, the Netherlands; and Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering (B.G., M.D.), University of Basel, Switzerland
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Menéndez-Valladares P, Acevedo Aguilera R, Núñez-Jurado D, López Azcárate C, Domínguez Mayoral AM, Fernández-Vega A, Pérez-Sánchez S, Lamana Vallverdú M, García-Sánchez MI, Morales Bravo M, Busquier T, Montaner J. A Search for New Biological Pathways in Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy by Proteomic Research. J Clin Med 2024; 13:3138. [PMID: 38892848 PMCID: PMC11172732 DOI: 10.3390/jcm13113138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a hereditary small vessel disease leading to significant morbidity and mortality. Despite advances in genetic diagnosis, the underlying pathophysiology remains incompletely understood. Proteomic studies offer insights into disease mechanisms by identifying altered protein expression patterns. Here, we conducted a proteomic analysis to elucidate molecular pathways associated with CADASIL. Methods: We enrolled genetically diagnosed CADASIL patients and healthy, genetically related controls. Plasma samples were subjected to proteomic analysis using the Olink platform, measuring 552 proteins across six panels. The data were analyzed from several approaches by using three different statistical methods: Exploratory Principal Component Analysis (PCA) and Partial Least Squares-Discriminant Analysis (PLS-DA), differential expression with moderated t-test, and gene set enrichment analysis (GSEA). In addition, bioinformatics analysis, including volcano plot, heatmap, and Variable Importance on Projection (VIP) scores from the PLS-DA model were drawn. Results: Significant differences in protein expression were observed between CADASIL patients and controls. RSPO1 and FGF-19 exhibited elevated levels (p < 0.05), while PPY showed downregulation (p < 0.05) in CADASIL patients, suggesting their involvement in disease pathogenesis. Furthermore, MIC-A/B expression varied significantly between patients with mutations in exon 4 versus exon 11 of the NOTCH3 gene (p < 0.05), highlighting potential immunological mechanisms underlying CADASIL. We identified altered pathways using GSEA, applied after ranking the study data. Conclusions: Our study provides novel insights into the proteomic profile of CADASIL, identifying dysregulated proteins associated with vascular pathology, metabolic dysregulation, and immune activation. These findings contribute to a deeper understanding of CADASIL pathophysiology and may inform the development of targeted therapeutic strategies. Further research is warranted to validate these biomarkers and elucidate their functional roles in disease progression.
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Affiliation(s)
- Paloma Menéndez-Valladares
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
- Department of Clinical Biochemistry, Virgen Macarena University Hospital, 41009 Seville, Spain
- Commission of Neurochemistry and Neurological Diseases, Spanish Society of Laboratory Medicine, 08025 Barcelona, Spain
| | - Rosa Acevedo Aguilera
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - David Núñez-Jurado
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
- Department of Clinical Biochemistry, Virgen Macarena University Hospital, 41009 Seville, Spain
| | - Cristina López Azcárate
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Ana María Domínguez Mayoral
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Alejandro Fernández-Vega
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Soledad Pérez-Sánchez
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Marcel Lamana Vallverdú
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | | | - María Morales Bravo
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Teresa Busquier
- Department of Radiology, Virgen Macarena University Hospital, 41009 Seville, Spain;
| | - Joan Montaner
- Department of Neurology, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.M.-V.); (R.A.A.); (D.N.-J.); (C.L.A.); (S.P.-S.); (M.L.V.); (M.M.B.); (J.M.)
- Department of Neurology, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
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Dupré N, Drieu A, Joutel A. Pathophysiology of cerebral small vessel disease: a journey through recent discoveries. J Clin Invest 2024; 134:e172841. [PMID: 38747292 PMCID: PMC11093606 DOI: 10.1172/jci172841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
Cerebral small vessel disease (cSVD) encompasses a heterogeneous group of age-related small vessel pathologies that affect multiple regions. Disease manifestations range from lesions incidentally detected on neuroimaging (white matter hyperintensities, small deep infarcts, microbleeds, or enlarged perivascular spaces) to severe disability and cognitive impairment. cSVD accounts for approximately 25% of ischemic strokes and the vast majority of spontaneous intracerebral hemorrhage and is also the most important vascular contributor to dementia. Despite its high prevalence and potentially long therapeutic window, there are still no mechanism-based treatments. Here, we provide an overview of the recent advances in this field. We summarize recent data highlighting the remarkable continuum between monogenic and multifactorial cSVDs involving NOTCH3, HTRA1, and COL4A1/A2 genes. Taking a vessel-centric view, we discuss possible cause-and-effect relationships between risk factors, structural and functional vessel changes, and disease manifestations, underscoring some major knowledge gaps. Although endothelial dysfunction is rightly considered a central feature of cSVD, the contributions of smooth muscle cells, pericytes, and other perivascular cells warrant continued investigation.
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Affiliation(s)
- Nicolas Dupré
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Antoine Drieu
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Anne Joutel
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
- GHU-Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
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Dupré N, Gueniot F, Domenga-Denier V, Dubosclard V, Nilles C, Hill-Eubanks D, Morgenthaler-Roth C, Nelson MT, Keime C, Danglot L, Joutel A. Protein aggregates containing wild-type and mutant NOTCH3 are major drivers of arterial pathology in CADASIL. J Clin Invest 2024; 134:e175789. [PMID: 38386425 PMCID: PMC11014667 DOI: 10.1172/jci175789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/20/2024] [Indexed: 02/24/2024] Open
Abstract
Loss of arterial smooth muscle cells (SMCs) and abnormal accumulation of the extracellular domain of the NOTCH3 receptor (Notch3ECD) are the 2 core features of CADASIL, a common cerebral small vessel disease caused by highly stereotyped dominant mutations in NOTCH3. Yet the relationship between NOTCH3 receptor activity, Notch3ECD accumulation, and arterial SMC loss has remained elusive, hampering the development of disease-modifying therapies. Using dedicated histopathological and multiscale imaging modalities, we could detect and quantify previously undetectable CADASIL-driven arterial SMC loss in the CNS of mice expressing the archetypal Arg169Cys mutation. We found that arterial pathology was more severe and Notch3ECD accumulation greater in transgenic mice overexpressing the mutation on a wild-type Notch3 background (TgNotch3R169C) than in knockin Notch3R170C/R170C mice expressing this mutation without a wild-type Notch3 copy. Notably, expression of Notch3-regulated genes was essentially unchanged in TgNotch3R169C arteries. We further showed that wild-type Notch3ECD coaggregated with mutant Notch3ECD and that elimination of 1 copy of wild-type Notch3 in TgNotch3R169C was sufficient to attenuate Notch3ECD accumulation and arterial pathology. These findings suggest that Notch3ECD accumulation, involving mutant and wild-type NOTCH3, is a major driver of arterial SMC loss in CADASIL, paving the way for NOTCH3-lowering therapeutic strategies.
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Affiliation(s)
- Nicolas Dupré
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Florian Gueniot
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Valérie Domenga-Denier
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Virginie Dubosclard
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Christelle Nilles
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - David Hill-Eubanks
- Department of Pharmacology, College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Christelle Morgenthaler-Roth
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, CNRS UMR 7104, INSERM U1258, Université de Strasbourg, Illkirch, France
| | - Mark T. Nelson
- Department of Pharmacology, College of Medicine, University of Vermont, Burlington, Vermont, USA
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Céline Keime
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, CNRS UMR 7104, INSERM U1258, Université de Strasbourg, Illkirch, France
| | - Lydia Danglot
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Anne Joutel
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
- Department of Pharmacology, College of Medicine, University of Vermont, Burlington, Vermont, USA
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
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Yuan L, Chen X, Jankovic J, Deng H. CADASIL: A NOTCH3-associated cerebral small vessel disease. J Adv Res 2024:S2090-1232(24)00001-8. [PMID: 38176524 DOI: 10.1016/j.jare.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/16/2023] [Accepted: 01/01/2024] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary cerebral small vessel disease (CSVD), pathologically characterized by a non-atherosclerotic and non-amyloid diffuse angiopathy primarily involving small to medium-sized penetrating arteries and leptomeningeal arteries. In 1996, mutation in the notch receptor 3 gene (NOTCH3) was identified as the cause of CADASIL. However, since that time other genetic CSVDs have been described, including the HtrA serine peptidase 1 gene-associated CSVD and the cathepsin A gene-associated CSVD, that clinically mimic the original phenotype. Though NOTCH3-associated CSVD is now a well-recognized hereditary disorder and the number of studies investigating this disease is increasing, the role of NOTCH3 in the pathogenesis of CADASIL remains elusive. AIM OF REVIEW This review aims to provide insights into the pathogenesis and the diagnosis of hereditary CSVDs, as well as personalized therapy, predictive approach, and targeted prevention. In this review, we summarize the current progress in CADASIL, including the clinical, neuroimaging, pathological, genetic, diagnostic, and therapeutic aspects, as well as differential diagnosis, in which the role of NOTCH3 mutations is highlighted. KEY SCIENTIFIC CONCEPTS OF REVIEW In this review, CADASIL is revisited as a NOTCH3-associated CSVD along with other hereditary CSVDs.
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Affiliation(s)
- Lamei Yuan
- Health Management Center, the Third Xiangya Hospital, Central South University, Changsha, China; Center for Experimental Medicine, the Third Xiangya Hospital, Central South University, Changsha, China; Disease Genome Research Center, Central South University, Changsha, China; Department of Neurology, the Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiangyu Chen
- Center for Experimental Medicine, the Third Xiangya Hospital, Central South University, Changsha, China; Disease Genome Research Center, Central South University, Changsha, China; Department of Pathology, Changsha Maternal and Child Health Care Hospital, Changsha, China
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Hao Deng
- Health Management Center, the Third Xiangya Hospital, Central South University, Changsha, China; Center for Experimental Medicine, the Third Xiangya Hospital, Central South University, Changsha, China; Disease Genome Research Center, Central South University, Changsha, China; Department of Neurology, the Third Xiangya Hospital, Central South University, Changsha, China.
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Cheng Y, Liao Y, Chen C, Chung C, Fann CSJ, Chang C, Lee Y, Tang S. Contribution of the APOE Genotype to Cognitive Impairment in Individuals With NOTCH3 Cysteine-Altering Variants. J Am Heart Assoc 2023; 12:e032689. [PMID: 37982214 PMCID: PMC10727295 DOI: 10.1161/jaha.123.032689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/23/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most prevalent monogenic cerebral small-vessel disease. Phenotype variability in CADASIL suggests the possible role of genetic modifiers. We aimed to investigate the contributions of the APOE genotype and Neurogenic locus notch homolog protein 3 (NOTCH3) variant position to cognitive impairment associated with CADASIL. METHODS AND RESULTS Patients with the cysteine-altering NOTCH3 variant were enrolled in a cross-sectional study, including the Mini-Mental State Examination (MMSE), brain magnetic resonance imaging, and APOE genotyping. Cognitive impairment was defined as an MMSE score <24. The associations between the MMSE score and genetic factors were assessed using linear regression models. Bayesian adjustment for confounding was used to identify clinical confounders. A total of 246 individuals were enrolled, among whom 210 (85%) harbored the p.R544C variant, 96 (39%) had cognitive impairment, and 150 (61%) had a history of stroke. The APOE ɛ2 allele was associated with a lower MMSE score (adjusted B, -4.090 [95% CI, -6.708 to -1.473]; P=0.023), whereas the NOTCH3 p.R544C variant was associated with a higher MMSE score (adjusted B, 2.854 [95% CI, 0.603-5.105]; P=0.0132) after adjustment for age, education, and history of ischemic stroke. Mediation analysis suggests that the associations between the APOE ɛ2 allele and MMSE score and between the NOTCH3 p.R544C variant and MMSE score are mediated by mesial temporal atrophy and white matter hyperintensity, respectively. CONCLUSIONS APOE genotype may modify cognitive impairment in CADASIL, whereby individuals carrying the APOE ɛ2 allele may present a more severe cognitive impairment.
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Affiliation(s)
- Yu‐Wen Cheng
- Department of NeurologyNational Taiwan University HospitalTaipeiTaiwan
| | - Yi‐Chu Liao
- Department of NeurologyTaipei Veterans General HospitalTaipeiTaiwan
- Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chih‐Hao Chen
- Department of NeurologyNational Taiwan University HospitalTaipeiTaiwan
| | - Chih‐Ping Chung
- Department of NeurologyTaipei Veterans General HospitalTaipeiTaiwan
| | | | | | - Yi‐Chung Lee
- Department of NeurologyTaipei Veterans General HospitalTaipeiTaiwan
- Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Sung‐Chun Tang
- Department of NeurologyNational Taiwan University HospitalTaipeiTaiwan
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8
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Takei J, Higuchi Y, Ando M, Yoshimura A, Yuan JH, Fujisaki N, Tokashiki T, Kanzato N, Jonosono M, Sueyoshi T, Kanda N, Matsuoka H, Okubo R, Suehara M, Matsuura E, Takashima H. Microbleed clustering in thalamus sign in CADASIL patients with NOTCH3 R75P mutation. Front Neurol 2023; 14:1241678. [PMID: 37681004 PMCID: PMC10480842 DOI: 10.3389/fneur.2023.1241678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Background and objective Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral microvascular disease characterized by the development of vascular dementia and lacunar infarctions. This study aimed to identify the genetic and clinical features of CADASIL in Japan. Methods We conducted genetic analysis on a case series of patients clinically diagnosed with CADASIL. Clinical and imaging analyses were performed on 32 patients with pathogenic mutations in the NOTCH3 gene. To assess the presence of cerebral microbleeds (CMBs), we utilized several established rating scales including the Fazekas scale, Scheltens rating scale, and Microbleed Anatomical Rating Scale, based on brain MRI images. Results Among the 32 CADASIL patients, 24 cases were found carrying the R75P mutation in NOTCH3, whereas the remaining eight cases had other NOTCH3 mutations (R75Q, R110C, C134F, C144F, R169C, and R607C). The haplotype analysis of the R75P mutation uncovered the presence of a founder effect. A brain MRI analysis revealed that cases with the R75P mutation had a significantly higher total number of CMBs, particularly in the thalamus when compared to patients with other NOTCH3 mutations. Among 15 out of 24 cases with the R75P mutation, we observed a notable clustering of CMBs in the thalamus, termed microbleed clustering in thalamus sign (MCT sign). Conclusion We propose that the MCT sign observed in NOTCH3 R75P-related CADASIL patients may serve as a potentially characteristic imaging feature. This finding offers further insights into the interactions between genotypes and phenotypes between NOTCH3 and CADASIL.
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Affiliation(s)
- Jun Takei
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yujiro Higuchi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masahiro Ando
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Akiko Yoshimura
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Jun-Hui Yuan
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Natsumi Fujisaki
- Department of Neurology, National Hospital Organization Okinawa Hospital, Okinawa, Japan
| | - Takashi Tokashiki
- Department of Neurology, National Hospital Organization Okinawa Hospital, Okinawa, Japan
| | - Naomi Kanzato
- Department of Neurology, Okinawa Prefectural Southern Medical Center & Children's Medical Center, Okinawa, Japan
| | - Manabu Jonosono
- Department of Neurology, Okinawa Chubu Hospital, Okinawa, Japan
| | | | - Naoaki Kanda
- Department of Neurology, Imamura General Hospital, Kagoshima, Japan
| | - Hideki Matsuoka
- Department of Cerebrovascular Medicine, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Ryuichi Okubo
- Department of Neurology, Fujimoto General Hospital, Miyazaki, Japan
| | - Masahito Suehara
- Department of Neurology, Fujimoto General Hospital, Miyazaki, Japan
| | - Eiji Matsuura
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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9
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Hack RJ, Gravesteijn G, Cerfontaine MN, Santcroos MA, Gatti L, Kopczak A, Bersano A, Duering M, Rutten JW, Lesnik Oberstein SAJ. Three-tiered EGFr domain risk stratification for individualized NOTCH3-small vessel disease prediction. Brain 2023; 146:2913-2927. [PMID: 36535904 PMCID: PMC10316769 DOI: 10.1093/brain/awac486] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 02/10/2024] Open
Abstract
Cysteine-altering missense variants (NOTCH3cys) in one of the 34 epidermal growth-factor-like repeat (EGFr) domains of the NOTCH3 protein are the cause of NOTCH3-associated small vessel disease (NOTCH3-SVD). NOTCH3-SVD is highly variable, ranging from cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) at the severe end of the spectrum to non-penetrance. The strongest known NOTCH3-SVD modifier is NOTCH3cys variant position: NOTCH3cys variants located in EGFr domains 1-6 are associated with a more severe phenotype than NOTCH3cys variants located in EGFr domains 7-34. The objective of this study was to further improve NOTCH3-SVD genotype-based risk prediction by using relative differences in NOTCH3cys variant frequencies between large CADASIL and population cohorts as a starting point. Scientific CADASIL literature, cohorts and population databases were queried for NOTCH3cys variants. For each EGFr domain, the relative difference in NOTCH3cys variant frequency (NVFOR) was calculated using genotypes of 2574 CADASIL patients and 1647 individuals from population databases. Based on NVFOR cut-off values, EGFr domains were classified as either low (LR-EGFr), medium (MR-EGFr) or high risk (HR-EGFr). The clinical relevance of this new three-tiered EGFr risk classification was cross-sectionally validated by comparing SVD imaging markers and clinical outcomes between EGFr risk categories using a genotype-phenotype data set of 434 CADASIL patients and 1003 NOTCH3cys positive community-dwelling individuals. CADASIL patients and community-dwelling individuals harboured 379 unique NOTCH3cys variants. Nine EGFr domains were classified as an HR-EGFr, which included EGFr domains 1-6, but additionally also EGFr domains 8, 11 and 26. Ten EGFr domains were classified as MR-EGFr and 11 as LR-EGFr. In the population genotype-phenotype data set, HR-EGFr individuals had the highest risk of stroke [odds ratio (OR) = 10.81, 95% confidence interval (CI): 5.46-21.37], followed by MR-EGFr individuals (OR = 1.81, 95% CI: 0.84-3.88) and LR-EGFr individuals (OR = 1 [reference]). MR-EGFr individuals had a significantly higher normalized white matter hyperintensity volume (nWMHv; P = 0.005) and peak width of skeletonized mean diffusivity (PSMD; P = 0.035) than LR-EGFr individuals. In the CADASIL genotype-phenotype data set, HR-EGFr domains 8, 11 and 26 patients had a significantly higher risk of stroke (P = 0.002), disability (P = 0.041), nWMHv (P = 1.8 × 10-8), PSMD (P = 2.6 × 10-8) and lacune volume (P = 0.006) than MR-EGFr patients. SVD imaging marker load and clinical outcomes were similar between HR-EGFr 1-6 patients and HR-EGFr 8, 11 and 26 patients. NVFOR was significantly associated with vascular NOTCH3 aggregation load (P = 0.006), but not with NOTCH3 signalling activity (P = 0.88). In conclusion, we identified three clinically distinct NOTCH3-SVD EGFr risk categories based on NFVOR cut-off values, and identified three additional HR-EGFr domains located outside of EGFr domains 1-6. This EGFr risk classification will provide an important key to individualized NOTCH3-SVD disease prediction.
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Affiliation(s)
- Remco J Hack
- Department of Clinical Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Gido Gravesteijn
- Department of Clinical Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Minne N Cerfontaine
- Department of Clinical Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark A Santcroos
- Department of Human Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Laura Gatti
- Laboratory of Neurobiology, Fondazione IRCSS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Anna Kopczak
- Institute for Stroke and Dementia Research, LMU University Hospital Munich, 81377 Munich, Germany
| | - Anna Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Marco Duering
- Institute for Stroke and Dementia Research, LMU University Hospital Munich, 81377 Munich, Germany
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, 4051 Basel, Switzerland
| | - Julie W Rutten
- Department of Clinical Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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10
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Mishra B, Vibha D, Tripathi M. Broadening the Genetic Horizons of CADASIL: New Variants of the NOTCH3 Gene Revealed and their Association with CADASIL. Ann Indian Acad Neurol 2023; 26:356-358. [PMID: 37970253 PMCID: PMC10645246 DOI: 10.4103/aian.aian_301_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Biswamohan Mishra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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11
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Haffner C. The emerging role of the HTRA1 protease in brain microvascular disease. FRONTIERS IN DEMENTIA 2023; 2:1146055. [PMID: 39081996 PMCID: PMC11285548 DOI: 10.3389/frdem.2023.1146055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/10/2023] [Indexed: 08/02/2024]
Abstract
Pathologies of the brain microvasculature, often referred to as cerebral small-vessel disease, are important contributors to vascular dementia, the second most common form of dementia in aging societies. In addition to their role in acute ischemic and hemorrhagic stroke, they have emerged as major cause of age-related cognitive decline in asymptomatic individuals. A central histological finding in these pathologies is the disruption of the vessel architecture including thickening of the vessel wall, narrowing of the vessel lumen and massive expansion of the mural extracellular matrix. The underlying molecular mechanisms are largely unknown, but from the investigation of several disease forms with defined etiology, high temperature requirement protein A1 (HTRA1), a secreted serine protease degrading primarily matrisomal substrates, has emerged as critical factor and potential therapeutic target. A genetically induced loss of HTRA1 function in humans is associated with cerebral autosomal-recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), a rare, hereditary form of brain microvascular disease. Recently, proteomic studies on cerebral amyloid angiopathy (CAA), a common cause of age-related dementia, and cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), the most prevalent monogenic small-vessel disease, have provided evidence for an impairment of HTRA1 activity through sequestration into pathological protein deposits, suggesting an alternative mechanism of HTRA1 inactivation and expanding the range of diseases with HTRA1 involvement. Further investigations of the mechanisms of HTRA1 regulation in the brain microvasculature might spawn novel strategies for the treatment of small-vessel pathologies.
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Affiliation(s)
- Christof Haffner
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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12
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Yamamoto Y, Liao YC, Lee YC, Ihara M, Choi JC. Update on the Epidemiology, Pathogenesis, and Biomarkers of Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy. J Clin Neurol 2023; 19:12-27. [PMID: 36606642 PMCID: PMC9833879 DOI: 10.3988/jcn.2023.19.1.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 01/04/2023] Open
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common monogenic disorder of the cerebral small blood vessels. It is caused by mutations in the NOTCH3 gene on chromosome 19, and more than 280 distinct pathogenic mutations have been reported to date. CADASIL was once considered a very rare disease with an estimated prevalence of 1.3-4.1 per 100,000 adults. However, recent large-scale genomic studies have revealed a high prevalence of pathogenic NOTCH3 variants among the general population, with the highest risk being among Asians. The disease severity and age at onset vary significantly even among individuals who carry the same NOTCH3 mutations. It is still unclear whether a significant genotype-phenotype correlation is present in CADASIL. The accumulation of granular osmiophilic material in the vasculature is a characteristic feature of CADASIL. However, the exact pathogenesis of CADASIL remains largely unclear despite various laboratory and clinical observations being made. Major hypotheses proposed so far have included aberrant NOTCH3 signaling, toxic aggregation, and abnormal matrisomes. Several characteristic features have been observed in the brain magnetic resonance images of patients with CADASIL, including subcortical lacunar lesions and white matter hyperintensities in the anterior temporal lobe or external capsule, which were useful in differentiating CADASIL from sporadic stroke in patients. The number of lacunes and the degree of brain atrophy were useful in predicting the clinical outcomes of patients with CADASIL. Several promising blood biomarkers have also recently been discovered for CADASIL, which require further research for validation.
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Affiliation(s)
- Yumi Yamamoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yi-Chu Liao
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chung Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea.,Institute for Medical Science, Jeju National University, Jeju, Korea
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13
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Dupé C, Guey S, Biard L, Dieng S, Lebenberg J, Grosset L, Alili N, Hervé D, Tournier-Lasserve E, Jouvent E, Chevret S, Chabriat H. Phenotypic variability in 446 CADASIL patients: Impact of NOTCH3 gene mutation location in addition to the effects of age, sex and vascular risk factors. J Cereb Blood Flow Metab 2023; 43:153-166. [PMID: 36254369 PMCID: PMC9875352 DOI: 10.1177/0271678x221126280] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The recent discovery that the prevalence of cysteine mutations in the NOTCH3 gene responsible for CADASIL was more than 100 times higher in the general population than that estimated in patients highlighted that the mutation location in EGFr-like-domains of the NOTCH3 receptor could have a major effect on the phenotype of the disease. The exact impact of such mutations locations on the multiple facets of the disease has not been fully evaluated. We aimed to describe the phenotypic spectrum of a large population of CADASIL patients and to investigate how this mutation location influenced various clinical and imaging features of the disease. Both a supervised and a non-supervised approach were used for analysis. The results confirmed that the mutation location is strongly related to clinical severity and showed that this effect is mainly driven by a different development of the most damaging ischemic tissue lesions at cerebral level. These effects were detected in addition to those of aging, male sex, hypertension and hypercholesterolemia. The exact mechanisms relating the location of mutations along the NOTCH3 receptor, the amount or properties of the resulting NOTCH3 products accumulating in the vessel wall, and their final consequences at cerebral level remain to be determined.
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Affiliation(s)
- Charlotte Dupé
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France.,UMR 1141 NeuroDiderot, INSERM and Université Paris Cité, Paris, France
| | - Stéphanie Guey
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France.,UMR 1141 NeuroDiderot, INSERM and Université Paris Cité, Paris, France
| | - Lucie Biard
- ECSTRRA Team, UMR-S 1153, Université Paris Cité, INSERM, Paris, France
| | - Sokhna Dieng
- ECSTRRA Team, UMR-S 1153, Université Paris Cité, INSERM, Paris, France
| | - Jessica Lebenberg
- UMR 1141 NeuroDiderot, INSERM and Université Paris Cité, Paris, France
| | - Lina Grosset
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France
| | - Nassira Alili
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France
| | - Dominique Hervé
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France
| | | | - Eric Jouvent
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France.,UMR 1141 NeuroDiderot, INSERM and Université Paris Cité, Paris, France
| | - Sylvie Chevret
- ECSTRRA Team, UMR-S 1153, Université Paris Cité, INSERM, Paris, France
| | - Hugues Chabriat
- Translational Neurovascular Centre (CERVCO) and Department of Neurology, FHU NeuroVasc, Hopital Lariboisière, Assistance Publique des Hôpitaux de Paris APHP, Université Paris Cité, Paris, France.,UMR 1141 NeuroDiderot, INSERM and Université Paris Cité, Paris, France
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14
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Cheng YW, Chao CC, Chen CH, Yeh TY, Jeng JS, Tang SC, Hsieh ST. Small Fiber Pathology in CADASIL: Clinical Correlation With Cognitive Impairment. Neurology 2022; 99:e583-e593. [PMID: 35584924 PMCID: PMC9442619 DOI: 10.1212/wnl.0000000000200672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/16/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study investigated the cutaneous small fiber pathology of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and its clinical significance, that is, the NOTCH3 deposition in cutaneous vasculatures and CNS neurodegeneration focusing on cognitive impairment. METHODS Thirty-seven patients with CADASIL and 59 age-matched healthy controls were enrolled to evaluate cutaneous small fiber pathology by quantitative measures of intraepidermal nerve fiber density (IENFD), sweat gland innervation, and vascular innervation. Cognitive performance of patients with CADASIL was evaluated by a comprehensive neuropsychological assessment, and its association with small fiber pathology was tested using multivariable linear regression analysis adjusted for age and diabetes mellitus. We further assessed the relationships of IENFD with cutaneous vascular NOTCH3 ectodomain (NOTCH3ECD) deposition and biomarkers of neurodegeneration including structural brain MRI measures, serum neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), tau, and ubiquitin carboxy-terminal hydrolase L1. RESULTS Patients with CADASIL showed reduced IENFD (5.22 ± 2.42 vs 7.88 ± 2.89 fibers/mm, p = 0.0001) and reduced sweat gland (p < 0.0001) and vascular (p < 0.0001) innervations compared with age-matched controls. Reduced IENFD was associated with impaired global cognition measured by Mini-Mental State Examination (B = 1.062, 95% CI = 0.370-1.753, p = 0.004), and this association remained after adjustment for age and diabetes mellitus (p = 0.043). In addition, IENFD in patients with CADASIL was associated with mean cortical thickness (Pearson r = 0.565, p = 0.0023) but not white matter hyperintensity volume, total lacune count, or total microbleed count. Reduced IENFD was associated with cutaneous vascular NOTCH3ECD deposition amount among patients harboring pathogenic variants in exon 11 (mainly p.R544C) (B = -0.092, 95% CI = -0.175 to -0.009, p = 0.031). Compared with those with normal cognition, patients with CADASIL with cognitive impairment had an elevated plasma NfL level regardless of concurrent small fiber denervation, whereas only patients with both cognitive impairment and small fiber denervation showed an elevated plasma GFAP level. DISCUSSION Cutaneous small fiber pathology correlates with cognitive impairment and CNS neurodegeneration in patients with CADASIL, indicating a peripheral neurodegenerative process related to NOTCH3ECD aggregation.
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Affiliation(s)
- Yu-Wen Cheng
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Chi-Chao Chao
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Chih-Hao Chen
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Ti-Yen Yeh
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Jiann-Shing Jeng
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Sung-Chun Tang
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Sung-Tsang Hsieh
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei.
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15
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Cho BPH, Jolly AA, Nannoni S, Tozer D, Bell S, Markus HS. Association of NOTCH3 Variant Position With Stroke Onset and Other Clinical Features Among Patients With CADASIL. Neurology 2022; 99:e430-e439. [PMID: 35641310 PMCID: PMC9421602 DOI: 10.1212/wnl.0000000000200744] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is caused by a cysteine-altering variant in 1 of the 34 epidermal growth factor-like repeat (EGFR) domains of the NOTCH3 protein. CADASIL has a variable phenotypic presentation, and NOTCH3 variants in EGFRs 1-6 have been found correlated with greater disease severity. We examined clinical and radiologic features and performed bioinformatic annotation of variants in a large CADASIL cohort to further understand these associations. METHODS We examined the association of NOTCH3 variant position on stroke onset and other clinical features among patients with CADASIL from the United Kingdom. We also explored how in silico predicted protein aggregation differed by variant position and the extent to which this affected stroke risk. RESULTS We identified 76 different cysteine-altering NOTCH3 variants in our cohort of 485 patients (mean age: 50.1 years; % male: 57.5). After controlling for cardiovascular risk factors, variants in EGFRs 1-6 were associated with earlier onset of stroke (hazard ratio [HR]: 2.05, 95% CI: 1.43-2.94) and encephalopathy (HR: 2.70, 95% CI: 1.15-6.37), than variants in EGFRs 7-34. Although the risk of stroke was higher in the patients with predicted protein aggregation (HR: 1.50, 95% CI: 1.05-2.14), this association was no longer significant after controlling for variant site. Further analysis suggested that lower stroke risk was observed for variants in EGFRs 10-17 compared with variants in the other EGFR domains. DISCUSSION NOTCH3 variant position is a predictor of stroke and encephalopathy in CADASIL independent of cardiovascular risk factors. Lower stroke risk was found for variants in EGFRs 10-17. Molecular factors that influence CADASIL disease severity remain to be determined.
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Affiliation(s)
- Bernard P H Cho
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Amy A Jolly
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Stefania Nannoni
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Daniel Tozer
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Steven Bell
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Hugh S Markus
- From the Department of Clinical Neurosciences, University of Cambridge, United Kingdom.
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16
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Hack RJ, Cerfontaine MN, Gravesteijn G, Tap S, Hafkemeijer A, van der Grond J, Witjes-Ané MN, Baas F, Rutten JW, Lesnik Oberstein SA. Effect of
NOTCH3
EGFr Group, Sex, and Cardiovascular Risk Factors on CADASIL Clinical and Neuroimaging Outcomes. Stroke 2022; 53:3133-3144. [PMID: 35862191 PMCID: PMC9508953 DOI: 10.1161/strokeaha.122.039325] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A retrospective study has shown that EGFr (epidermal growth factor–like repeat) group in the NOTCH3 gene is an important cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) disease modifier of age at first stroke and white matter hyperintensity (WMH) volume. No study has yet assessed the effect of other known CADASIL modifiers, that is, cardiovascular risk factors and sex, in the context of NOTCH3 EGFr group. In this study, we determined the relative disease-modifying effects of NOTCH3 EGFr group, sex and cardiovascular risk factor on disease severity in the first genotype-driven, large prospective CADASIL cohort study, using a comprehensive battery of CADASIL clinical outcomes and neuroimaging markers.
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Affiliation(s)
- Remco J. Hack
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Minne N. Cerfontaine
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Gido Gravesteijn
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Stephan Tap
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Anne Hafkemeijer
- Department of Radiology, Leiden University Medical Center, the Netherlands. (A.H., J.v.d.G.)
- Institute of Psychology, Leiden University, the Netherlands. (A.H.)
- Leiden Institute for Brain and Cognition, Leiden University, the Netherlands. (A.H.)
| | - Jeroen van der Grond
- Department of Radiology, Leiden University Medical Center, the Netherlands. (A.H., J.v.d.G.)
| | - Marie-Noëlle Witjes-Ané
- Department of Geriatrics and Psychiatrics, Leiden University Medical Center, the Netherlands. (M.N.W.-A.)
| | - Frank Baas
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Julie W. Rutten
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
| | - Saskia A.J. Lesnik Oberstein
- Department of Clinical Genetics, Leiden University Medical Center, the Netherlands. (R.J.H., M.N.C., G.G., S.T., F.B., J.W.R., S.A.J.L.O.)
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17
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Ueda A, Nakajima M, Misumi Y, Nakahara K, Shinriki S, Tasaki M, Matsui H, Ueda M. Detection of Vascular Notch3 Deposits in Unfixed Frozen Skin Biopsy Sample in CADASIL. Front Neurol 2022; 13:881528. [PMID: 35775048 PMCID: PMC9239429 DOI: 10.3389/fneur.2022.881528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to evaluate the utility of immunohistochemical staining of vascular Notch3 deposits in biopsied unfixed frozen skin samples from patients with suspected cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We analyzed vascular Notch3 deposits in unfixed frozen skin biopsy samples obtained from 43 patients with suspected CADASIL by immunohistochemistry using antibodies against the extracellular domain (ECD) of Notch3. We also sequenced the NOTCH3 gene in all patients, as well as evaluated their symptoms and neuroimages. We found granular Notch3 ECD deposits in the vessel walls of unfixed frozen skin biopsy samples in 10 of the 43 suspected patients with CADASIL. All 10 cases with skin Notch3 ECD deposits also carried reported pathogenic variants in the NOTCH3 gene associated with CADASIL. NOTCH3 variants of unknown significance were found in the other four patients without vascular Notch3 ECD or granular osmiophilic material deposits in biopsied skin samples. The remaining 29 cases without vascular Notch3 ECD deposits did not have variants in the NOTCH3 gene. Immunohistochemical evaluation of vascular Notch3 ECD deposits in unfixed frozen biopsied skin samples may be useful for detecting Notch3 deposits in CADASIL.
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Affiliation(s)
- Akihiko Ueda
- Department of Neurology, Kumamoto University, Kumamoto, Japan
- *Correspondence: Akihiko Ueda
| | - Makoto Nakajima
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Yohei Misumi
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | | | - Satoru Shinriki
- Department of Molecular Laboratory Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masayoshi Tasaki
- Department of Neurology, Kumamoto University, Kumamoto, Japan
- Department of Biomedical Laboratory Sciences, Graduate School of Health Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotaka Matsui
- Department of Molecular Laboratory Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Kumamoto University, Kumamoto, Japan
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18
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Hack RJ, Gravesteijn G, Cerfontaine MN, Hegeman IM, Mulder AA, Lesnik Oberstein SA, Rutten JW. Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy Family Members With a Pathogenic NOTCH3 Variant Can Have a Normal Brain Magnetic Resonance Imaging and Skin Biopsy Beyond Age 50 Years. Stroke 2022; 53:1964-1974. [PMID: 35300531 PMCID: PMC9126263 DOI: 10.1161/strokeaha.121.036307] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/16/2021] [Accepted: 12/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND To determine whether extremely mild small vessel disease (SVD) phenotypes can occur in NOTCH3 variant carriers from Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) pedigrees using clinical, genetic, neuroimaging, and skin biopsy findings. METHODS Individuals from CADASIL pedigrees fulfilling criteria for extremely mild NOTCH3-associated SVD (mSVDNOTCH3) were selected from the cross-sectional Dutch CADASIL cohort (n=200), enrolled between 2017 and 2020. Brain magnetic resonance imaging were quantitatively assessed for SVD imaging markers. Immunohistochemistry and electron microscopy was used to quantitatively assess and compare NOTCH3 ectodomain (NOTCH3ECD) aggregation and granular osmiophilic material deposits in the skin vasculature of mSVDNOTCH3 cases and symptomatic CADASIL patients. RESULTS Seven cases were identified that fulfilled the mSVDNOTCH3 criteria, with a mean age of 56.6 years (range, 50-72). All of these individuals harbored a NOTCH3 variant located in one of EGFr domains 7-34 and had a normal brain magnetic resonance imaging, except the oldest individual, aged 72, who had beginning confluence of WMH (Fazekas score 2) and 1 cerebral microbleed. mSVDNOTCH3 cases had very low levels of NOTCH3ECD aggregation in skin vasculature, which was significantly less than in symptomatic EGFr 7-34 CADASIL patients (P=0.01). Six mSVDNOTCH3 cases had absence of granular osmiophilic material deposits. CONCLUSIONS Our findings demonstrate that extremely mild SVD phenotypes can occur in individuals from CADASIL pedigrees harboring NOTCH3 EGFr 7-34 variants with normal brain magnetic resonance imaging up to age 58 years. Our study has important implications for CADASIL diagnosis, disease prediction, and the counseling of individuals from EGFr 7-34 CADASIL pedigrees.
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Affiliation(s)
- Remco J. Hack
- Department of Clinical Genetics (R.J.H., G.G., M.N.C., S.A.J.L.O., J.W.R.), Leiden University Medical Center, the Netherlands
| | - Gido Gravesteijn
- Department of Clinical Genetics (R.J.H., G.G., M.N.C., S.A.J.L.O., J.W.R.), Leiden University Medical Center, the Netherlands
| | - Minne N. Cerfontaine
- Department of Clinical Genetics (R.J.H., G.G., M.N.C., S.A.J.L.O., J.W.R.), Leiden University Medical Center, the Netherlands
| | - Ingrid M. Hegeman
- Department of Pathology (I.M.H.), Leiden University Medical Center, the Netherlands
| | - Aat A. Mulder
- Department of Cell and Chemical Biology (A.A.M.), Leiden University Medical Center, the Netherlands
| | - Saskia A.J. Lesnik Oberstein
- Department of Clinical Genetics (R.J.H., G.G., M.N.C., S.A.J.L.O., J.W.R.), Leiden University Medical Center, the Netherlands
| | - Julie W. Rutten
- Department of Clinical Genetics (R.J.H., G.G., M.N.C., S.A.J.L.O., J.W.R.), Leiden University Medical Center, the Netherlands
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