FROM ASYMPTOMATIC CARRIERS TO CADASIL: CONTEXT-DEPENDENT PHENOTYPIC VARIABILITY OF THE NOTCH3 P.ARG1231CYS VARIANT ACROSS THREE EUROPEAN COHORTS AND POTENTIAL IMPLICATIONS OF LDL CHOLESTEROL
- 1Universite Paris-Saclay, UVSQ, Inserm, CESP, 94807, Villejuif, France
Abstract
BackgroundCADASIL caused by cysteine-altering NOTCH3 variants, the most frequent hereditary cerebral small vessel disease worldwide, is characterized by marked phenotypic variability. Mutation location within the EGFr domains of the NOTCH3 receptor has emerged as a key determinant of this variability. We investigated phenotypic variability and potential modifiers of CADASIL expression by comparing individuals harbouring the same pathogenic NOTCH3 variant across distinct recruitment settings in three European countries.
MethodsWe compared clinical features, MRI markers, and cardiovascular risk factors among individuals harbouring the p.Arg1231Cys NOTCH3 mutation across three distinct recruitment settings: a multigenerational founder population from Cilento, Italy (CILCAD), a population-based cohort from the UK Biobank (UKB), and a clinically referred cohort from a national referral centre in Lariboisiere Hospital, Paris, France (LRB). In addition, CILCAD carriers were compared with NON-Carriers from the same population. The NOTCH3 locus was finally analysed to define the shared haplotype in CILCAD and explore potential genetic contributions to phenotypic variability.
FindingsBy comparing populations from three European countries, this study showed marked context-dependent phenotypic variability associated with the sole pathogenic p.Arg1231Cys NOTCH3 variant. In CILCAD, a multigenerational founder population, the haplotype carrying the NOTCH3 mutation also predisposes to decreased LDL levels, resulting in an unusually low LDL cholesterol profile in this sample. Strikingly, these very low LDL levels were associated with a higher likelihood of stroke.
InterpretationIn European carriers of NOTCH3 p.Arg1231Cys, factors beyond mutation location, including genetic background, may substantially shape disease expression, while exceptionally low LDL levels could paradoxically be associated with greater disease severity.
RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSCADASIL, the most frequent hereditary cerebral small vessel disease worldwide, is caused by cysteine-altering NOTCH3 mutations and is characterised by marked phenotypic variability. A position effect has emerged as a key determinant: mutations in proximal EGFr domains 1-6 associate with severe, early-onset disease, while distal domain mutations (7-34) typically result in milder phenotypes. Among distal mutations, p.Arg1231Cys is the most frequent in European populations. Beyond mutation location, hypertension and smoking have been identified as phenotypic modifiers, whereas the role of LDL cholesterol remains unclear, largely due to methodological limitations and confounding by statin use.
Added value of this studyThis is the first study to assess phenotypic variability of a single CADASIL-causing mutation across three distinct European recruitment settings. We show that ascertainment context profoundly shapes the observed phenotype, revealing a clinical spectrum from entirely asymptomatic individuals to severe cerebrovascular disease. Genetic characterisation of the Italian founder population CILCAD identified an extended haplotype harbouring LDL-lowering alleles, establishing it as a unique model for studying low LDL in CADASIL. Strikingly, very low LDL levels were associated with a higher likelihood of stroke rather than cerebrovascular protection.
Implications of all the available evidencePhenotypic variability of the p.Arg1231Cys NOTCH3 variant extends well beyond what mutation location predicts, with ascertainment context and additional genetic or environmental modifiers playing a substantial role. These findings have direct implications for disease burden estimation, genetic counselling, and epidemiological study design. The potential deleterious association between very low LDL and stroke challenges the extrapolation of lipid-lowering targets from atherosclerotic disease to CADASIL, and warrants prospective investigation in larger longitudinal cohorts.
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BibTeX
@misc{nutile2026from,
title = {{FROM ASYMPTOMATIC CARRIERS TO CADASIL: CONTEXT-DEPENDENT PHENOTYPIC VARIABILITY OF THE NOTCH3 P.ARG1231CYS VARIANT ACROSS THREE EUROPEAN COHORTS AND POTENTIAL IMPLICATIONS OF LDL CHOLESTEROL}},
author = {T. Nutile and D. Ruggiero and M. Pluntz and J. Lebenberg and L. Lambert and L. Cipriano and A. Di Pietro and V. Sandroni and P. Cennamo and D. Herve and S. Guey and M. D. Calabrese and S. Lucibello and A. F. Herzig and L. Trojano and V. Pizza and E. Tournier-Lasserve and H. Perdry and H. Chabriat and A.-L. Leutenegger and M. Ciullo},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.03.26364647},
url = {https://www.medrxiv.org/content/10.64898/2026.10.03.26364647v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - FROM ASYMPTOMATIC CARRIERS TO CADASIL: CONTEXT-DEPENDENT PHENOTYPIC VARIABILITY OF THE NOTCH3 P.ARG1231CYS VARIANT ACROSS THREE EUROPEAN COHORTS AND POTENTIAL IMPLICATIONS OF LDL CHOLESTEROL
AU - T. Nutile
AU - D. Ruggiero
AU - M. Pluntz
AU - J. Lebenberg
AU - L. Lambert
AU - L. Cipriano
AU - A. Di Pietro
AU - V. Sandroni
AU - P. Cennamo
AU - D. Herve
AU - S. Guey
AU - M. D. Calabrese
AU - S. Lucibello
AU - A. F. Herzig
AU - L. Trojano
AU - V. Pizza
AU - E. Tournier-Lasserve
AU - H. Perdry
AU - H. Chabriat
AU - A.-L. Leutenegger
AU - M. Ciullo
PY - 2026
DA - 2026/10/03
PB - medRxiv
DO - 10.64898/2026.10.03.26364647
UR - https://www.medrxiv.org/content/10.64898/2026.10.03.26364647v1
AB - BackgroundCADASIL caused by cysteine-altering NOTCH3 variants, the most frequent hereditary cerebral small vessel disease worldwide, is characterized by marked phenotypic variability. Mutation location within the EGFr domains of the NOTCH3 receptor has emerged as a key determinant of this variability. We investigated phenotypic variability and potential modifiers of CADASIL expression by comparing individuals harbouring the same pathogenic NOTCH3 variant across distinct recruitment settings in three European countries. MethodsWe compared clinical features, MRI markers, and cardiovascular risk factors among individuals harbouring the p.Arg1231Cys NOTCH3 mutation across three distinct recruitment settings: a multigenerational founder population from Cilento, Italy (CILCAD), a population-based cohort from the UK Biobank (UKB), and a clinically referred cohort from a national referral centre in Lariboisiere Hospital, Paris, France (LRB). In addition, CILCAD carriers were compared with NON-Carriers from the same population. The NOTCH3 locus was finally analysed to define the shared haplotype in CILCAD and explore potential genetic contributions to phenotypic variability. FindingsBy comparing populations from three European countries, this study showed marked context-dependent phenotypic variability associated with the sole pathogenic p.Arg1231Cys NOTCH3 variant. In CILCAD, a multigenerational founder population, the haplotype carrying the NOTCH3 mutation also predisposes to decreased LDL levels, resulting in an unusually low LDL cholesterol profile in this sample. Strikingly, these very low LDL levels were associated with a higher likelihood of stroke. InterpretationIn European carriers of NOTCH3 p.Arg1231Cys, factors beyond mutation location, including genetic background, may substantially shape disease expression, while exceptionally low LDL levels could paradoxically be associated with greater disease severity. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSCADASIL, the most frequent hereditary cerebral small vessel disease worldwide, is caused by cysteine-altering NOTCH3 mutations and is characterised by marked phenotypic variability. A position effect has emerged as a key determinant: mutations in proximal EGFr domains 1-6 associate with severe, early-onset disease, while distal domain mutations (7-34) typically result in milder phenotypes. Among distal mutations, p.Arg1231Cys is the most frequent in European populations. Beyond mutation location, hypertension and smoking have been identified as phenotypic modifiers, whereas the role of LDL cholesterol remains unclear, largely due to methodological limitations and confounding by statin use. Added value of this studyThis is the first study to assess phenotypic variability of a single CADASIL-causing mutation across three distinct European recruitment settings. We show that ascertainment context profoundly shapes the observed phenotype, revealing a clinical spectrum from entirely asymptomatic individuals to severe cerebrovascular disease. Genetic characterisation of the Italian founder population CILCAD identified an extended haplotype harbouring LDL-lowering alleles, establishing it as a unique model for studying low LDL in CADASIL. Strikingly, very low LDL levels were associated with a higher likelihood of stroke rather than cerebrovascular protection. Implications of all the available evidencePhenotypic variability of the p.Arg1231Cys NOTCH3 variant extends well beyond what mutation location predicts, with ascertainment context and additional genetic or environmental modifiers playing a substantial role. These findings have direct implications for disease burden estimation, genetic counselling, and epidemiological study design. The potential deleterious association between very low LDL and stroke challenges the extrapolation of lipid-lowering targets from atherosclerotic disease to CADASIL, and warrants prospective investigation in larger longitudinal cohorts.
ER -