CADASIL: a practical review for the neurologist

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy) is a hereditary small vessel disease caused by pathogenic NOTCH3 variants, predominantly affecting cysteine residues in epidermal growth factor-like repeats. Clinically, patients present with migraine with aura, subcortical ischaemic strokes, mood disturbances, apathy and progressive cognitive decline, with disability accumulating over decades. Neuroimaging typically shows symmetrical white matter hyperintensities, lacunar infarcts and cerebral microbleeds. Its diagnosis relies on genetic testing, with skin biopsy reserved for uncertain cases. Management remains supportive and symptom-directed, emphasising vascular risk-factor control, stroke prevention, migraine management and cognitive and multidisciplinary care. Emerging therapeutic strategies targeting NOTCH3 include exon skipping, gene silencing, immunotherapy, growth factors and peptides, with preclinical studies showing restoration of mural cell function, reduced protein aggregation and improved vascular and cognitive outcomes. We need further research to translate these approaches into safe and effective disease-modifying therapies for patients.