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Cadasil Pathogenesis, Clinical and Radiological Findings and Treatment View and review Arq Neuropsiquiatr 2010;68(2):287-299 Cadasil Pathogenesis, clinical and radiological findings and treatment Charles André ABSTRACT Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common genetic cause of ischemic strokes and a most important model for the study of subcortical vascular dementia. This unrelentlessly progressive disease affects many hundreds of families all over the world but is not well studied in Brazil. This manuscript reviews pathogenetic, clinical, radiological and therapeutic features of CADASIL. The causal mutations are now very well known, but the same can not be said about its intimate pathogenetic mechanisms. The variable clinical presentation should lead physicians to actively pursue the diagnosis in many settings and to more thouroughly investigate family history in first degree relatives. A rational approach to genetic testing is however needed. Treatment of CADASIL is still largely empiric. High- quality therapeutic studies involving medications and cognitive interventions are strongly needed in CADASIL. Key words: CADASIL, etiology, genetics, diagnosis, therapeutics. CADASIL: patogênese, achados clínicos e radiológicos e tratamento RESUMO CADASIL é a causa genética mais freqüente de infartos cerebrais e constitui modelo importante de estudo de demências vasculares subcorticais. De natureza inexoravelmente progressiva, afeta milhares de pessoas em todo o mundo. Sua importância é pouco reconhecida entre nós, o que nos levou à presente revisão dos principais aspectos patogenéticos, clínicos, neuroradiológicos e terapêuticos da doença. As mutações causais são hoje bem conhecidas, mas os mecanismos patogenéticos íntimos ainda permanecem misteriosos. A apresentação clínica variável deve fazer com que os médicos considerem o diagnóstico em vários contextos clínicos e investiguem de forma mais extensa que o usual a história familial deparentes de primeiro grau. Além disso, uma abordagem racional é necessária para reduzir custos e aumentar a eficiência do diagnóstico genético. O tratamento atual de pacientes com CADASIL é basicamente empírico. Estudos clínicos sobre medicamentos e intervenções cognitivas de alto nível metodológico constituem uma necessidade urgente. Palavras-chave: CADASIL, etiologia, genética, diagnóstico, terapêutica. CADASIL (cerebral autosomal domi- tations are diverse and in most individu- nant arteriopathy with subcortical infarcts als include recurrent headache of migraine Correspondence and leukoencephalopathy) is a hereditary pattern, focal deficits secondary to brain Charles André disease with high penetrance in which oc- infarction (more rarely bleeding) and, in Av Rodolpho Paulo Rocco 255 clusion of small arteries in the brain of later stages, progressive neuropsychiatric Serviço de Neurologia 10E36 Cidade Universitária adults results in small deep brain infarcts disorders including dementia. 21941-913 Rio de Janeiro RJ - Brasil and progressive accumulation of demy- This article reviews the main aspects E-mail: [email protected] elination areas in the brain. Its manifes- of this puzzling disease, which constitutes Received 4 November 2009 Accepted 18 November 2009 Associate Professor of Neurology, School of Medicine: Federal University of Rio de Janeiro, Rio de Janeiro RJ, Brazil. 287 CADASIL André Arq Neuropsiquiatr 2010;68(2) the main genetic cause of stroke. Emphasis is given to er-Lasserve and cols. found that the gene responsible cognitive and neuropsychiatric symptoms. for CADASIL should be located on chromosome 19 in a 14-cM centimorgans) segment between D19S221 and definitions D19S2221. As two other autosomal dominant diseases - CADASIL is an autosomal dominant disease result- familial hemiplegic migraine and episodic hereditary cer- ing from mutations of the gene encoding the transmem- ebellar ataxia - were also mapped on chromosome 19 in brane receptor Notch 3, located on chromosome 19. Re- close proximity with CADASIL, the question of allelism garded as a prototype of subcortical vascular dementia re- in these three conditions soon arised2,3. lated to subcortical microangiopathy, it also results in ad- The 14-cM segment on chromosome 19q12 was pro- ditional psychiatric disorders, particularly mood chang- gressively reduced in successive studies, until Joutel et es, usually in association with the development of cogni- al. were able to reduce it to a critical 800 kb interval that tive impairment. would probably contain the gene for CADASIL, now in The disease is reported in several countries from all 19p13.14. Among several genes in this region, there was continents. Its frequency is probably underestimated and one that exhibited strong homology with Notch 3 gene CADASIL may be one of the most common inherited neu- encoding region 5 in mice. Further studies showed that rological conditions. The prevalence of Notch 3 gene muta- the human homologue of the Notch 3 gene actually was tions has been estimated as more than 4 per 100,000 adults. located in that critical 800 Kb region5. The disease appears in adult life. Its manifestations are In the last decade, more than 80 Notch 3 mutations virtually restricted to the central nervous system, espe- were identified in more than 400 families with CADASIL. cially the brain, and are caused by the progressive devel- These mutations are distributed across 34 repetitions of opment of disseminated white matter lesions in associ- the epidermal growth factor (EGFR) that comprise the ex- ation with small infarcts - lacunes - in subcortical areas. tracellular domain of Notch 36. All mutations responsible Migraine with aura and focal neurologic deficits caused for CADASIL lead to an odd number of cysteine residues. by these lacunar infarctions are characteristic forms of The Notch 3 gene encodes a single pass transmem- presentation in young or middle age. Over the years, brane receptor comprising 2,321 amino acids with an ex- mood disorders, diverse neurological deficits and cogni- tracellular domain containing 34 epidermal growth factor tive disturbances add up. To the extent that the total vol- (EGF)-like repeats (with 6 cysteine residues in each) and 3 ume of lesions increases and cerebral atrophy develops, Lin-12 repeats related to the transmembrane and intracel- the frequency and severity of motor difficulties and cog- lular domains . It consists of 33 exons (23 extracellular)5,7,8 nitive dysfunction also increase. (Fig 1A). All mutations occur in extracellular domains, The cognitive disorder is progressive, and typically re- more specifically the epidermal growth-like factor-re- flects accumulating injury resulting from subcortical mi- peats (EGF-repeats), from a non-paired cysteine4,7. Most crovascular disease. Initially, difficulties in information mutations occur in codons of exon 4, followed by exons processing and slowing of cognitive processes are most 3, 5, 6 and 117,9,10 (Fig 1B). The exon 3 seems to be the sec- evident; later, changes in memory and other high order ond most commonly affected site in French, English and cognitive functions lead to the development of dementia. German families7,9; exon 11 could, however, be the sec- Depression is the commonest mood disorder, occurring in ond most prevalent in Dutch families11. 20% of individuals. In the final stages, individuals are bed- The Notch proteins constitute a family of surface re- driden, apathetic and totally dependent. Death usually re- ceptors that promote transduction of signals between sults from medical complications, especially malnutrition neighboring cells. Their interaction with ligands leads to and infectious diseases such as aspiration pneumonia. cleavage of its intracellular portion, which translocates to the nucleus and activates transcription of specific factors, Genetics and pathogenesis thus regulating subsequent gene expression (Fig 1). The genetics of CADASIL is directly linked to that of This signaling pathway has been highly preserved the Notch receptor family. These surface receptors medi- throughout phylogeny, and seems to exert a central role ate signal transduction with ligands (such as Jagged [Jag] in determining cell fate during embryonic development, and Delta [D]) in neighboring cells, which are also type I including various aspects of vascular development such transmembrane receptors. Notch 3 mutations are respon- as vasculogenesis, angiogenesis, vascular remodeling, sible for CADASIL, whose main characteristic is a vascu- and differentiation of VSMC12,13. In humans, mutations lar degeneration, indicating that this system plays an im- in one Notch ligand system cause congenital abnormali- portant role in maintaining structural stability and func- ties (Alagille syndrome - OMIM # 118450). In adults, evi- tion of vascular smooth muscle cells (VSMC). dence of involvement of abnormalities in the regulation of Studying two large French families in 1993, Tourni- Notch signaling system accumulates, even in cancer8. 288 CADASIL Arq Neuropsiquiatr 2010;68(2) André Fig 1. The classic NOTCH signaling pathway (a) and schematic diagram of the Notch 3 mutations identified in patients with CADASIL (b) (compressed and adapted from Wang T et al. ref. 8). A.The Notch receptor locates at cell surface as a heterodi- mer following protease cleavage (S1) during protein matu- ration. The extracellular domain (NECD) - containing up to 36 EGF-repeats and three cysteine-rich Notch/LIN-12 repeats (LNG domain) - associates non-covalently with a membrane- tethered intracellular
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