Vascular NOTCH3 Deposition Load: Association With NOTCH3 Genotype and CADASIL Disease Severity.

BACKGROUND AND OBJECTIVES: Vascular NOTCH3 extracellular domain (NOTCH3ECD) deposition is the pathologic hallmark of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We aimed to explore the relationships among the NOTCH3ECD deposition load, the NOTCH3 variant genotype, and cerebral small vessel disease (SVD) severity. METHODS: Fifty-four individuals carrying NOTCH3 pathogenic variants were enrolled and underwent skin biopsy for the quantification of dermal vascular NOTCH3ECD deposition load using immunohistochemical staining. The NOTCH3ECD deposition load, defined as the percentage of the NOTCH3ECD-stained area within the vessel area marked by smooth muscle actin staining, was compared among NOTCH3 p.R544C heterozygotes (n = 46), p.R544C homozygotes (n = 3), and individuals with pathogenic variants in epidermal growth factor-like repeats (EGFr) 1-6 and 8 (n = 5). In NOTCH3 p.R544C heterozygotes, we further investigated the associations between the NOTCH3ECD deposition load and various clinical and imaging severity measures of cerebral SVD using regression models adjusted for age, sex, and hypertension. RESULTS: The NOTCH3ECD deposition load was greater in individuals with NOTCH3 variants located in EGFr 1-6 and 8 (93.21%) and in p.R544C homozygotes (56.63%) than in p.R544C heterozygotes (16.37%, p = 0.0004 and 0.0296, respectively). In NOTCH3 p.R544C heterozygotes, no statistically significant associations were found between NOTCH3ECD load and disease severity stage, stroke incidence, Mini-Mental State Examination score, or functional independence. Regarding MRI features, a greater NOTCH3ECD load was associated with an increased cerebral microbleed count (B = 0.074, 95% CI = 0.014-0.135, p = 0.018) but was not associated with white matter hyperintensity burden, lacune count, or brain parenchymal fraction after adjustment for age, sex, and hypertension. DISCUSSION: The NOTCH3 variant genotype is a key determinant of the vascular NOTCH3ECD deposition load. The weak association between CADASIL disease severity and NOTCH3ECD deposition load suggests the importance of modifying factors that contribute to the diverse clinical spectrum of NOTCH3 vasculopathy.