Introduction

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, OMIM#125310) is an autosomal dominant inherited small vessel disease (SVD) caused by mutations in the NOTCH3 gene (19p13). Its real prevalence is unknown, although some studies have shown that up to 4.1/100,000 individuals suffer from CADASIL1,2, and as many as 3.2–3.4/1000 general individuals carry cysteine-related missense variant of NOTCH33,4.

The extracellular domain (ECD) of Notch3 is constituted by 34 epidermal growth factor-like repeats (EGFr), each of which contains six cysteine residues. Pathogenic mutations lead to an odd number of these cysteines, disrupting disulfide bridge formation and leading to Notch3 protein misfolding, multimerization and aggregation5,6,7. This is the main etiopathogenic hypothesis. However, it is not fully understood. It is thought that this protein aggregation could lead to a toxic gain of function, as seems to occur with TIMP3 and vitronectin (VTN), proteins associated with vessel extracellular matrix8,9, or even interfere with autophag 10 or cause endoplasmic reticulum stress11. Likewise, a proteomic study highlighted the differential protein levels between CADASIL patients and controls regarding extracellular matrix and mitochondrial proteins12. However, no robust transcriptomics studies have been carried out in patients with CADASIL.

Because of its systemic nature, the study of different biopsy tissues, such as brain, muscle and skin, has made it possible to examine the histopathological changes that take place in CADASIL for a better comprehension of the disease, such as the loss of endothelial cells, pericytes and vascular smooth muscle cells (VSMC), as well as intercellular or cell–matrix adhesions13,14. Actually, the hallmark of the disease, granular osmiophilic materials (GOMs) constituted partly by Notch3 ECD15, has a sensitivity of 45–96% and a specificity of 100% for CADASIL diagnosis16.

The main symptoms of CADASIL are migraine, psychiatric disorders, recurrent small subcortical infarctions and dementia17. Regarding cognitive impairment, 60% of patients aged > 60 years have dementia, and impaired executive function (EF) was detected globally in 87.5% of individuals18.

Our aim was to identify mRNA differentially expressed in skin biopsies of CADASIL patients through a genome-wide transcriptome study (GWTS) that could be relevant for understanding the etiopathogenesis of the disease, identifying relevant pathways, therapeutic targets for future studies, as well as to study their association with cognitive performance.

Methods

This is an observational case–control study to discover differential mRNA expression and enrichment pathways through a genome-wide transcriptome study (GWTS) using microarray technology. For the validation of the significant differentially expressed mRNAs, we performed a qRT-PCR assay with a new cohort of cases and controls, and in situ hybridization (ISH), which will also allow us to locate significant differentially expressed mRNA.

Subjects

Subjects were selected from “CADAGENIA”, a registry in which patients with mutations in NOTCH3 have been consecutively recorded since 2017 from different parts of Spain, mostly Catalonia (Hospital Vall d’Hebron and Hospital del Mar, Barcelona). For matching purposes, control relatives (such as spouses or siblings) without a known NOTCH3 mutation were asked to enroll in the registry to avoid any potential bias due to differences between cases and controls, as well as other healthy volunteers.

Epidemiological data, blood analyses, cognition and neuroimaging profiles and skin biopsies were registered.

The inclusion criteria for cases for this differential expression study were: (1) age > 17 years, (2) having a cysteine-affecting NOTCH3 missense mutation (CNMM), and (3) having a skin biopsy available. The exclusion criteria were: (1) age < 18 years, (2) having a NOTCH3 mutation other than CNMM, and (3) not having a skin biopsy available.

The inclusion criteria for controls were: (1) age > 17 years, and (2) agreeing to have a skin biopsy. The exclusion criteria were: (1) age < 18 years, (2) having a known NOTCH3 mutation, and (3) not having a skin biopsy available.

As additional inclusion criteria for the GWTS, CADASIL patients and controls had to be matched with family members. For the qRT-PCR and ISH assays, this criterion was not needed. None of the controls was related to the cases in the qRT-PCR or in the ISH study.

For ISH, all nine cases had been studied with the qRT-PCR. Of the eight controls, seven had been studied with qRT-PCR and one with the GWTS.

Variables

Detailed clinical-epidemiological data were collected from each patient, including age; sex; vascular risk factors, such as hypertension defined as two measures on different days with blood pressure exceeding 140/90 mmHg or taking antihypertensive treatment; diabetes mellitus (DM), defined as basal glycemia in venous plasma ≥ 126 mg/dl, 2-h post-load plasma glycemia ≥ 200 mg/dl or HbA1c ≥ 6.5% or taking antidiabetic treatment; dyslipidemia; smoking habits; and type of mutation.

The cognitive profile was determined in patients with NOTCH3 mutations by means of a complete neuropsychological examination. The evaluated cognitive domains included: verbal memory, working memory, executive function, attention and information processing speed, motor speed and dexterity, and visuoconstructional skills.

For global cognition, the Montreal Cognitive Assessment (MOCA) was used as a screening test. Verbal memory was evaluated through the short-term total learning and delayed recall subtests from the Wechsler memory scale-III (WMS-III) word list. Working memory was determined by the forward and backward digits subtests from the Wechsler Adult Intelligence Scale (WAIS-III). EF was assessed by means of: phonetic (letters “P”, “M” and “R”) and semantic category (animals) verbal fluencies, the Stroop Color-Word test—number of words—and the Trail Making Test part B (TMT-B)—execution time. Attention and information processing speed (IPS) were evaluated through the Symbol Digit Modalities Test (SDMT), Stroop Word and Color tests—number of words—and the Trail Making Test part A (TMT-A)—execution time. Motor speed and dexterity were rated by the Purdue Pegboard test, considering the dominant, non-dominant and both-hand trials. Visuoconstructional skills were evaluated by means of the block designs subtest from the WAIS-III.

Raw scores were adjusted into Z-scores by age and years of education following Spanish normative data19,20,21. A higher adjusted Z-score indicates a better performance in all cases. We calculated cognitive domain indices by averaging the adjusted scores within each domain.

RNA extraction

A 6-mm skin punch biopsy was obtained for each participant in the study. The homogenization of the tissue was carried out with the TissueRuptor (Quiagen) and the RNA was extracted with a RNeasy Plus Micro Kit (Quiagen), following the manufacturer’s instructions.

Genome-wide transcriptome study

From each sample, 10 ng of total RNA was used as the starting material. The quality of the isolated RNA was measured previously by capillary electrophoresis using a NanoChip (Bioanalyzer 2100, Agilent). Single-stranded cDNA suitable for labeling was generated from the total RNA using the GeneChip WT Pico Reagent Kit (Thermo Fisher Scientific) according to the manufacturer’s instructions. This kit makes it possible to generate robust expression profiles from as little as 100 pg of total RNA (10 cells). Purified sense-strand cDNA was fragmented, labeled and hybridized to the arrays using the GeneChip Hybridization, Wash and Stain Kit from the same manufacturer. Finally, Affymetrix Human Clariom S Pico Assay was the microarray used to study the expression. After array scanning, raw data quality control was performed to check the overall performance of the processing.

qRT-PCR

For this assay, we selected the two most significantly differentially expressed mRNAs from the GWTS (p-value < 10–3). As CADASIL is an arteriopathy that leads to brain hypoxemia, we wanted to select the genes from the GWTS that were related to neuronal ischemia in order to show a possible link and that belonged to the top fifteen most significant differentially expressed mRNAs. Therefore, we conducted a bibliographic search in PubMed with the term “(ischemi*[Title/Abstract]) AND gene[Title/Abstract]”.

As previously reported22, mRNA levels were measured by qRT-PCR using TaqMan fluorogenic probes (see Supplementary Table I for those used in this study) on a 7500 Real-Time PCR System (Applied Biosystems, CA, USA). PPIA expression was used to normalize the results, as has been described previously22.

qRT-PCR was performed using a standard TaqMan PCR kit protocol consisting of 20 µl of PCR mix, including 5 µl of cDNA, 10 µl of 2 × TaqMan Universal PCR Master Mix (P/N: 4304437, Applied Biosystems, Foster city, CA, USA), 1 µl of TaqMan gene expression assay and 4 µl of water. Reactions were performed in two 384-well plates at 50 °C for two min and at 95 °C for 10 min, followed by 40 cycles at 95 °C for 15 s and 60 °C for one min. All reactions were run in triplicate and analyzed using the RQ App on Thermo Fisher Connect, following standard quality controls to assess the samples.

The results were a relative quantification (RQ) between the cycles of each sample relative to a single calibrator control sample.

ISH

Formalin-fixed human skin tissues were embedded in paraffin, cut at 3–4 μm and stained with RNAscope Probe—Hs-E2F4—E2F Transcription Factor 4 probe (898351, Bio-techne) using RNAscope Intro Pack 2.5 HD Reagent Kit Red (322350, Bio-techne).

Thereafter, anti-CD31 antibody (ab28364, Abcam), used as a marker of vessels23 and the mouse monoclonal alpha smooth muscle Actin antibody [1A4] (αSMA) (ab7817, Abcam) used as a marker of myofibroblasts/fibroblasts23 and VSMC, were used for immunofluorescence. DAPI staining was used to stain all nuclei.

Full images of sections were acquired with a NanoZoomer-2.0 HT C9600 scanner (Hamamatsu) at 20× magnification. QuPAth open software was used to perform image analysis24. Region of interests (ROIs) were selected manually in all the tissue sections, including the full dermis, and excluding the epidermis and sebaceous/sudoriferous glands.

A positive pixel count algorithm was used to detect CD31 cells or αSMA, and they were segmented in positive or negative. Subcellular detection was used afterwards to detect the number of E2F4 spots, which were segmented in dots (up to 6 µm2) or clusters (> 6 µm2).

For the quantitative analysis we only considered those CD31+ cells that are surrounded by αSMA+ cells and vice versa, and can therefore be said to be EC and VSMC.

Statistical methods

Statistical and bioinformatics analyses were performed using custom scripts in R language, version 3.6.0 (R Core Team, 2019), with common Bioconductor packages. For the GWTS, after following a standard quality control, the Robust Multi-array Average (RMA) algorithm was used for pre-processing transcriptome data in order to perform background adjustment, normalization and summarization of the probe set expression values. Then, genes whose standard deviation (SD) was below the 65 percentiles of all the SD values, without a known Entrez Gene database identifier and without a valid annotation to the Gene Ontology database, were filtered out from the whole dataset and finally 6485 genes were considered for the statistical analysis. Selection of differentially expressed elements was based on a linear model analysis with empirical Bayes modification for the variance estimates. To deal with the false‐discovery rate derived from multiple test comparisons, p-values were adjusted with the Benjamini and Hochberg method25, considering genes with an adjusted p-value < 0.05 to be statistically significant.

The two most significant differentially expressed mRNAs from the GWTS (p-value < 10–3) were evaluated in the replication cohort by qRT-PCR. Another two significant differentially expressed mRNAs from the top fifteen that were associated with ischemic neuronal death were also analyzed.

As the inclusion of outlying values could lead to erroneous interpretations26, a box plot was performed for their identification. We used the “ggbetweenstats” function from the “ggstatsplot” package library. To know whether the outliers were statistically significant, and therefore that sample should be excluded, a Dixon's Q test was performed with the “dixon.test” function from the “outliers” package.

A p-value < 0.05 was considered statistically significant, after Bonferroni multivariable test correction, in the validation analysis.

For the ISH, a box plot was created with the “ggplot2” package library. Samples with values below quartile 1 minus 1.5 times the interquartile range, or above quartile 3 plus 1.5 times the interquartile range, were considered outliers for that analysis and therefore removed. A p-value < 0.05 was considered statistically significant.

To assess statistical significance, Fisher's Exact Test was used for categorical variables and a Mann–Whitney U test was used for not normally distributed continuous variables or ordinal variables. The T-test was used for normal and homoscedastic continuous variables. Pearson’s test was used to study the correlation between normal numeric variables.

Expression profile

Brain expression of the mRNAs replicated in the qRT-PCR was studied using the GTEx Portal (https://gtexportal.org/home/) and expression by brain cell type was studied in the Single-nuclei Brain RNA-seq expression browser (http://ngi.pub/snuclRNA-seq/).

Enrichment pathways analysis

The analysis of biological significance was based on gene set enrichment analysis (GSEA), which makes it possible to detect situations where all genes in a predefined set change in a small but coordinated way27. The analysis has been performed over two annotation databases: the “Gene Ontology”(GO) and the Reactome Pathway Knowledge base28.

All the filtered genes analyzed in the GWTS were ranked by log2 fold change and were used in the analysis. For GO, analysis was performed regarding biological process (BP), cellular component (CC) and molecular function (MF). GO terms and Reactome Pathways were considered enriched with a raw p-value under 0.01.

An enrichment map of the top 60 terms or pathways found for each comparison was performed (for GO terms enriched in the category of Molecular Function there were just 11 terms, and 37 for the enriched pathways). This map groups gene ontology (GO) terms/pathways by similarity. Nodes are colored by p-value and their size reflects the number of genes found in that term.

Ethical issues

All protocols were carried out in accordance with the guidelines and national regulations, being approved by the local ethics committee (Hospital del Mar and Hospital Vall d’Hebron). A written informed consent document was provided before any study procedure was performed and it was signed by the patient or representative.

Results

Differential expression study

GWTS study

For the GWTS study, we had four CADASIL patients corresponding to three different families, and three sibling controls without CNMM, one per family, in the CADAGENIA registry. These seven patients constituted the discovery cohort. Ten CADASIL patients and eight controls matched by age and sex constituted the validation cohort; blood relatives were not mandatory. No statistically significant differences between cases and controls were observed in age, sex, smoking habits, hypertension, diabetes mellitus, dyslipidemia, migraine, psychiatric disease, stroke or dementia (Table 1).

Table 1 Clinical-epidemiological features of the GWTS, qRT-PCR and ISH assay cohorts.
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For the distribution of the mutations in the cases of the Discovery/Validation analyses, see Fig. 1.

Figure 1
figure 1

Distribution of mutations from the cases of the GWTS and qRT-PCR studies. Chr chromosome.

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The GWTS did not show statistically significant differential expression after Benjamini and Hochberg correction (Table 2).

Table 2 Top fifteen most differentially expressed mRNAs from the Genome-Wide Transcriptome study.
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qRT-PCR study

The two genes with the smallest p-values (p-value < 10–3) (Table 1): BANP, p-value = 7.23 × 10–4 and PDCD6IP, p-value = 8.36 × 10–4, both downregulated in cases; and the two most relevant mRNAs associated with ischemic neuronal death from the top fifteen most significant differentially expressed mRNAs: CAMK2G, downregulated in cases (p-value = 4.52 × 10–3), and E2F4, upregulated in cases (p-value = 4.77 × 10–3), were selected for a second study using qRT-PCR in a new cohort of ten CADASIL patients and eight controls.

In the qRT-PCR assay (Table 3), E2F4 mRNA levels were significantly higher in CADASIL patients compared with controls after Bonferroni correction (relative quantification of 1.84 ± 1.09 in cases and 0.66 ± 0.11 in controls, raw p-value = 1.23 × 10–3; Bonferroni threshold: 1.25 × 10–2; see Fig. 2A).

Table 3 Mean, standard deviation and p-values of the mRNAs from the qRT-PCR assay.
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Figure 2
figure 2

E2F4 expression. (A) E2F4 relative quantification box plot for cases and controls from the qRT-PCR experiment. (B) Proportion of CD31 positive cells with E2F4 expression. (C) Proportion of αSMA positive cells with E2F4 expression.

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ISH

This cohort was constituted by nine cases and eight controls. Sixteen of them were chosen from the GWTS and one from the qRT-PCR study, due to their availability for the ISH. None of the controls was related to the cases.

ISH with E2F4 probe revealed positive labeling in the epidermis, some cells of the dermis and some cells of the skin adnexa. E2F4 dots were located on nuclei and in the cytosolic subcellular compartment (Fig. 3).

Figure 3
figure 3

In situ hybridization of E2F4 in dermis. Fluorescence for E2F4 is shown in orange, for CD31 in red and for αSMA in green. The image above corresponds to a case and the image below to a control. The red arrows indicate E2F4 positivity in a CD31-positive cell. Green arrows indicate E2F4 positivity in an SMA-positive cell. The asterisk indicates an E2F4 cluster.

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CD31 positive labeling presented a membranous pattern and was seen in some cells of the dermis. αSMA positive cells presented cytoplasmic labeling and were seen in cells surrounding the CD31 positive cells and below the epithelial cells of sebaceous/sudoriferous glands.

We did not find significant difference of E2F4 expression level between cases and controls (Table 4 and Fig. 2).

Table 4 Statistical summary of the in situ hybridization.
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Cognition evaluation

To study the relationship between E2F4 and neuropsychological performance, five CADASIL patients with qRT-PCR data were analyzed. Each neuropsychological domain (ND) was altered in > 50% of the patients, except visuoconstructional function. See Supplementary Table II, Supplementary Fig. I.

A significant association was observed with EF, correlation = − 0.93, p-value = 2.04 × 10–2, and a tendency was observed in attention and IPS, correlation = − 0.82, p = 8.73 × 10–2, adjusted by age and educational level (Table 5). Higher E2F4 expression was associated with a worse score in the EF and IPS tests. The other cognitive domains were not associated with E2F4.

Table 5 p-value of the association between E2F4 levels and domain alteration, adjusted by age and educational level.
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Expression profile

The GTEx Portal showed E2F4 is expressed in the brain, as well as in other tissues (Supplementary Fig. II), and the SNBREB showed that it is also expressed in brain endothelial cells (Supplementary Fig. III).

Pathway enrichment analysis

GO terms and Reactome Pathways were considered enriched with a raw p-value under 0.01, since none of the analyses reached a significant p-value after correction for multiple comparisons. See Supplementary Figs. IV–V and Supplementary Tables III–IV.

In the BP analysis (Supplementary Fig. IV), we observed the network related to vascular development, and catabolic and autophagy processes, and in the CC analysis (Supplementary Fig. V), the enrichment in vesicular machinery and cell adhesion terms.

Discussion

E2F4 mRNA was associated with CADASIL patients and was upregulated in the skin biopsies of cases vs controls in the GWTS and the qRT-PCR study. The expression profile showed that E2F4 is widely expressed (GTEx portal), including endothelial cells in the brain (SNBREB database). Moreover, our ISH confirmed E2F4 expression in endothelium and VSMCs, cells that are characteristically affected in the disease.

We did not find significant difference of E2F4 expression level between cases and controls in our ISH. The lack of statistical significance could be due to sampling bias, limited number of slices and limited number of vessels in a slice, among others.

Besides, E2F4 expression was additionally inversely correlated with EF and attention and IPS, which are the principal cognitive functions that are altered in CADASIL29.

Whether E2F4 might be useful as a biomarker of early detection of cognitive impairment and monitoring of the course of the disease should be addressed by increasing the number of patients. For practical use, it is necessary to identify blood biomarkers reflecting E2F4 expression level in skin biopsy.

The E2F4 protein belongs to the E2F family of transcription factors and plays a crucial role in controlling the cell cycle. E2F4 has expression in endothelial cells, as we have shown in the ISH, and it is necessary for its correct migration30. A diminished expression of E2F4 attenuates the endothelial cell migration, and its subsequent overexpression could rescue normal endothelial migration30.

E2F4 is also expressed in VSMC31, also evidenced in our ISH. Actually, it is involved in the process of intimal hyperplasia (IH), which is the proliferation of VSMCs in the media and their migration into the tunica intima of the vessel. Mice lacking E2F4 exhibit increased IH following arterial damage31.

Both, endothelial cells and VSMC, are key cells in the aetiopathology of this disease, which highlights the relevance of the finding of E2F4 as a mRNA differentially expressed. These cells have been found to be altered in CADASIL histopathological studies13,32,33 and they are involved in blood flow regulation, a mechanism that has been seen to be altered in numerous studies focusing on this disease34,35,36.

Besides, E2F4 have been related to neuronal survival in ischemic situations. Previous studies observed that primary cerebellar granule neurons (CGNs) overexpressing E2F4 vs controls had higher survival after an ischemic insult37. Nevertheless, E2F4 levels decreased after hypoxia in non-infected CGNs. Overexpression of E2F4 had no effect on neuronal viability in the absence of ischemia.

E2F4 is also part of a complex containing Smad3, which acts as a transducer of transforming growth factor-β (TGFβ) signals38. TGFβ is a protein related to hereditary SVDs39 such as CARASIL, caused by HTRA1 gene mutations. HTRA1 is also associated with LTBP-1 and they regulate bioavailability of TGFβ40. Importantly, these two proteins have been associated with Notch3 ECD deposits41 and HTRA1 has shown less activity in CADASIL patients42.

Whether the elevated expression of E2F4 is due to a compensatory mechanism for a lack of protein production or whether the protein is actually elevated, is still unclear.

In view of the above, it would seem more likely that there was an increase in E2F4 protein levels. In CADASIL, there is a loss of VSMC13,14, and the absence of E2F4 activity leads to increased proliferation of VSMC31. In addition, increased mRNA and protein levels of E2F4 could indicate an overactivation of the TGFβ pathway in CADASIL patients, a molecule widely associated with SVD39 and fibrosis43. Actually, TGFβ1 is implicated in cell proliferation, differentiation, apoptosis, autophagy and extracellular matrix protein production44.

This is a study of gene expression through microarray technology and validation by real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR)22.

So far, proteomic studies in CADASIL have identified an enrichment of extracellular matrix proteins, mitochondrial proteins12, proteins associated with degradation and folding, contraction of VSMC, and cellular stress45. They have provided valuable information for understanding the disease, such as finding the enrichment of HTRA1 and colocalizing it with Notch3 ECD deposits, linking the molecular pathways between CADASIL and CARASIL12. They have also made it possible to see that TIMP3 and vitronectin (VTN) are sequestered by Notch3 ECD deposits46, leading to studies that showed that high levels of TIMP3 and VTN play a role in CADASIL, producing diverging influences on CBF deficits and white matter lesions8.

Transcriptomic studies are a complementary approach that analyzes the different potential mechanisms associated with CADASIL. Moreover, transcriptomics could be highly correlated with clinical traits compared with protein levels in mice47.

Despite the lack of significant results after correction by multiple tests, the pathway studies have shown an increase in the biological processes related to vascular development, which is remarkable because CADASIL is a systemic arteriopathy caused by NOTCH3, a gene related to vascular morphogenesis.

GO analysis have also shown an increase in cellular component terms related to cell adhesion. Additionally, it should be noted that histopathological studies of CADASIL have shown a change in or loss of cellular junctions between VSMC or the adjacent extracellular matrix and endothelial adhesion13,14,33.

Moreover, the pathway analysis has shown an enrichment of component cells terms related to vesicular machinery and the biological process of autophagy. Several articles have pointed out that this cellular clearance pathway could be impaired in CADASIL, causing a deficiency in the elimination of Notch3 aggregates10,48,49.

Limitations

This study has several limitations. Firstly, the small sample size due to the low frequency of the disease in question. Matching the patients by age and sex and by family in the GWTS allowed us to minimize biases in the interpretation of the results.

Secondly, the target organ in CADASIL is the brain, but samples were obtained from skin tissue. Nevertheless, histopathological studies of skin biopsies have shown the typical hallmarks of the disease and have been used to understand its etiopathogenesis13,32,33. Besides, post-mortem brain tissue can be problematic for transcriptomic analysis due to apoptotic and necrotic processes that change the gene expression, causing bias in omics experiments.

Thirdly, the GWTS study did not present significant differentially expressed mRNAs associated with CADASIL after adjusting for multiple comparisons. Massive data studies in low prevalence diseases such as CADASIL, which include different types of cells, may have the inconvenience of presenting less power to detect statistical significance when small differences exist, even if they are determinant. Choosing the mRNAs most significantly associated with CADASIL in the GWTS for evaluation by the qRT-PCR technique may be a useful and valid approach. Genetic studies in CADASIL have also had to resort to the use of non-significant data to deal with this lack of power, subsequently obtaining data of scientific interest. For example, the creation of a polygenic score from the most significant SNPs associated with WMH volume in CADASIL patients, suggesting that multiple SNPs with small effects modify the total WMH load in patients with CADASIL, rather than SNPs with larger effects50.

Finally, as in the skin there are lymphatic blood vessels with endothelial cells, we cannot totally exclude that some of the CD31 positive cells found in the ISH, might be also labelling those. In the same way, there are other cells in the skin that might be positive to αSMA, such as fibroblast. Nevertheless, lymphoid vessels do not present the smooth muscle layer around them, therefore it can be assumed that the vast majority of CD31 immunostained cells corresponded to endothelial cells and the αSMA positive cells surrounding these endothelial cells were VSMC. We have checked histologically when doing the image analysis quantification that CD31 positive cells were surrounded by αSMA positive cells.

Conclusions

Our results showed higher levels of E2F4 mRNA in CADASIL skin biopsies and the highest levels of expression were associated with the worst EF and attention and IPS in five of the qRT-PCR CADASIL cases.

E2F4 is a protein expressed in endothelial and VSMC (confirmed in our ISH), controlling the migration of the former and the proliferation and migration of the latter, which are cells that are characteristically affected in the disease. Besides, it is a protein that is related to neuronal survival in ischemic conditions and the TGFβ pathway. E2F4 should be studied further to clarify whether its expression levels might help to monitor the disease and cognitive status, making it important for future clinical trials or even for therapeutic targeting. Further studies are needed to elucidate the role of E2F4 in CADASIL.