Therapeutic antibody targeting of Notch3 signaling prevents mural cell loss in CADASIL.

Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CAD.ASIL) is a neurological syndrome characterized by small vessel disease (SVD), stroke, and vascular cognitive impairment and dementia caused by mutations in NOTCH3. No therapies are available for this condition. Loss of mural cells, which encompass pericytes and vascular smooth muscle cells, is a hallmark of CAD.ASIL and other SVDs, including diabetic retinopathy, resulting in vascular instability. Here, we showed that Notch3 signaling is both necessary and sufficient to support mural cell coverage in arteries using genetic rescue in Notch3 knockout mice. Furthermore, we show that systemic administration of an agonist Notch3 antibody prevents mural cell loss and modifies plasma proteins associated with Notch3 activity, including endostatin/collagen 18 alpha 1 and Notch3 extracellular domain in mice with the C455R mutation, a CAD.ASIL variant associated with Notch3 loss of function. These findings open opportunities for the treatment of CAD.ASIL and other SVDs by modulating Notch3 signaling.