{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T08:39:58Z","timestamp":1792485598680,"version":"4.5.0"},"reference-count":29,"publisher":"Oxford University Press (OUP)","issue":"11","license":[{"start":{"date-parts":[[2020,1,21]],"date-time":"2020-01-21T00:00:00Z","timestamp":1579564800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000942","name":"Brain Foundation","doi-asserted-by":"publisher","award":["HA2016-02-03"],"award-info":[{"award-number":["HA2016-02-03"]}],"id":[{"id":"10.13039\/501100000942","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000942","name":"Brain Foundation","doi-asserted-by":"publisher","award":["BG2015-2"],"award-info":[{"award-number":["BG2015-2"]}],"id":[{"id":"10.13039\/501100000942","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,7,21]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>CADASIL is a vascular protein aggregation disorder caused by cysteine-altering NOTCH3 variants, leading to mid-adult-onset stroke and dementia. Here, we report individuals with a cysteine-altering NOTCH3 variant that induces exon 9 skipping, mimicking therapeutic NOTCH3 cysteine correction. The index came to our attention after a coincidental finding on a commercial screening MRI, revealing white matter hyperintensities. A heterozygous NOTCH3 c.1492G&amp;gt;T, p.Gly498Cys variant, was identified using a gene panel, which was also present in four first- and second-degree relatives. Although some degree of white matter hyperintensities was present on MRI in all family members with the NOTCH3 variant, the CADASIL phenotype was mild, as none had lacunes on MRI and there was no disability or cognitive impairment above the age of 60\u00a0years. RT-PCR and Sanger sequencing analysis on patient fibroblast RNA revealed that exon 9 was absent from the majority of NOTCH3 transcripts of the mutant allele, effectively excluding the mutation. NOTCH3 aggregation was assessed in skin biopsies using electron microscopy and immunohistochemistry and did not show granular osmiophilic material and only very mild NOTCH3 staining. For purposes of therapeutic translatability, we show that, in cell models, exon 9 exclusion can be obtained using antisense-mediated exon skipping and CRISPR\/Cas9-mediated genome editing. In conclusion, this study provides the first in-human evidence that cysteine corrective NOTCH3 exon skipping is associated with less NOTCH3 aggregation and an attenuated phenotype, justifying further therapeutic development of NOTCH3 cysteine correction for CADASIL.<\/jats:p>","DOI":"10.1093\/hmg\/ddz285","type":"journal-article","created":{"date-parts":[[2019,11,26]],"date-time":"2019-11-26T20:09:49Z","timestamp":1574798989000},"page":"1853-1863","source":"Crossref","is-referenced-by-count":21,"title":["Naturally occurring NOTCH3 exon skipping attenuates NOTCH3 protein aggregation and disease severity in CADASIL patients"],"prefix":"10.1093","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2610-8728","authenticated-orcid":false,"given":"Gido","family":"Gravesteijn","sequence":"first","affiliation":[{"name":"Department of Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes G","family":"Dauwerse","sequence":"additional","affiliation":[{"name":"Department of Human Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8143-4884","authenticated-orcid":false,"given":"Maurice","family":"Overzier","sequence":"additional","affiliation":[{"name":"Department of Human Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9853-7142","authenticated-orcid":false,"given":"Gwendolyn","family":"Brouwer","sequence":"additional","affiliation":[{"name":"Department of Human Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingrid","family":"Hegeman","sequence":"additional","affiliation":[{"name":"Department of Pathology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4779-099X","authenticated-orcid":false,"given":"Aat A","family":"Mulder","sequence":"additional","affiliation":[{"name":"Department of Cell and Chemical Biology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3912-5428","authenticated-orcid":false,"given":"Frank","family":"Baas","sequence":"additional","affiliation":[{"name":"Department of Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4319-834X","authenticated-orcid":false,"given":"Mark C","family":"Kruit","sequence":"additional","affiliation":[{"name":"Department of Radiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3140-6882","authenticated-orcid":false,"given":"Gisela M","family":"Terwindt","sequence":"additional","affiliation":[{"name":"Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4682-8869","authenticated-orcid":false,"given":"Sjoerd G","family":"van Duinen","sequence":"additional","affiliation":[{"name":"Department of Pathology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8342-1094","authenticated-orcid":false,"given":"Carolina R","family":"Jost","sequence":"additional","affiliation":[{"name":"Department of Cell and Chemical Biology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1565-654X","authenticated-orcid":false,"given":"Annemieke","family":"Aartsma-Rus","sequence":"additional","affiliation":[{"name":"Department of Human Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1268-8995","authenticated-orcid":false,"given":"Saskia A J","family":"Lesnik Oberstein","sequence":"additional","affiliation":[{"name":"Department of Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3250-7263","authenticated-orcid":false,"given":"Julie W","family":"Rutten","sequence":"additional","affiliation":[{"name":"Department of Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"},{"name":"Department of Human Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,1,21]]},"reference":[{"key":"2020072105164978700_ref1","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/S1474-4422(09)70127-9","article-title":"Cadasil","volume":"8","author":"Chabriat","year":"2009","journal-title":"Lancet Neurol."},{"key":"2020072105164978700_ref2","doi-asserted-by":"crossref","first-page":"707","DOI":"10.1038\/383707a0","article-title":"Notch3 mutations in CADASIL, a 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Rev. Mol. Diagn."},{"key":"2020072105164978700_ref4","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s00401-002-0530-z","article-title":"Morphometric analysis of ultrastructural vascular changes in CADASIL: analysis of 50 skin biopsy specimens and pathogenic implications","volume":"104","author":"Brulin","year":"2002","journal-title":"Acta Neuropathol."},{"key":"2020072105164978700_ref5","doi-asserted-by":"crossref","first-page":"2049","DOI":"10.1016\/S0140-6736(01)07142-2","article-title":"Skin biopsy immunostaining with a Notch3 monoclonal antibody for CADASIL diagnosis","volume":"358","author":"Joutel","year":"2001","journal-title":"Lancet"},{"key":"2020072105164978700_ref6","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1007\/s00401-003-0701-6","article-title":"Evaluation of diagnostic NOTCH3 immunostaining in CADASIL","volume":"106","author":"Lesnik Oberstein","year":"2003","journal-title":"Acta Neuropathol."},{"key":"2020072105164978700_ref7","doi-asserted-by":"crossref","DOI":"10.1016\/j.neulet.2019.01.014","article-title":"Clinical and research applications of magnetic resonance imaging in the study of CADASIL","author":"Schoemaker","year":"2019","journal-title":"Neurosci. Lett. [Internet]"},{"key":"2020072105164978700_ref8","doi-asserted-by":"crossref","first-page":"1123","DOI":"10.1093\/brain\/aww011","article-title":"Therapeutic NOTCH3 cysteine correction in CADASIL using exon skipping: in vitro proof of concept","volume":"139","author":"Rutten","year":"2016","journal-title":"Brain"},{"key":"2020072105164978700_ref9","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1148\/radiol.2293021354","article-title":"Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy: MR imaging findings at different ages\u20143rd\u20136th decades","volume":"229","author":"van den Boom","year":"2003","journal-title":"Radiology"},{"key":"2020072105164978700_ref10","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1038\/s41436-018-0088-3","article-title":"The effect of NOTCH3 pathogenic variant position on CADASIL disease severity: NOTCH3 EGFr 1-6 pathogenic variant are associated with a more severe phenotype and lower survival compared with EGFr 7-34 pathogenic variant","volume":"21","author":"Rutten","year":"2018","journal-title":"Genet. Med."},{"key":"2020072105164978700_ref11","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1186\/s40478-015-0268-1","article-title":"The NOTCH3 score: a pre-clinical CADASIL biomarker in a novel human genomic NOTCH3 transgenic mouse model with early progressive vascular NOTCH3 accumulation","volume":"3","author":"Rutten","year":"2015","journal-title":"Acta Neuropathol. Commun."},{"key":"2020072105164978700_ref12","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1172\/JCI39733","article-title":"Cerebrovascular dysfunction and microcirculation rarefaction precede white matter lesions in a mouse genetic model of cerebral ischemic small vessel disease","volume":"120","author":"Joutel","year":"2010","journal-title":"J. Clin. 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