title: Diagnostic strategies in CADASIL.
abstract: BACKGROUND
  Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited autosomal dominant condition characterized by migraine, recurrent stroke, and dementia. It results from mutations in the notch3 gene but mutations may occur at multiple sites making molecular diagnosis time consuming. It has been suggested that the presence of granular osmiophilic material (GOM) on skin biopsy and involvement of the anterior temporal lobe and external capsule on MRI may help in diagnosis.
  
  
  METHODS
  The authors identified 83 potential index cases from the British population and screened exons 2 to 23 of notch3. MRI scans were scored using a modified Scheltens scale. Skin biopsy was performed in a subgroup.
  
  
  RESULTS
  Fifteen different point mutations were identified in 48 families, 73% of which were in exon 4, 8% in exon 3, and 6% in each of exons 5 and 6. Moderate or severe involvement of the anterior temporal pole on MRI had a sensitivity of 89% and specificity of 86% for diagnosis of CADASIL, whereas external capsule involvement had a high sensitivity of 93% but a low specificity of 45%. Skin biopsy, performed in 18 cases, had a sensitivity of 45% and specificity of 100%.
  
  
  CONCLUSIONS
  The spectrum of mutations in this study can be used to plan appropriate screening protocols; a suggested protocol is to screen exon 4, and proceed to exons 3, 5, and 6 where indicated. GOM on skin biopsy is diagnostic but can be negative. Anterior temporal pole involvement on MRI is a useful diagnostic marker.
authors.affiliation: Department of Clinical Neuroscience, St. George's Hospital Medical School, London, UK.
authors.forename: H S
authors.initials: HS
authors.lastname: Markus
authors.forename: R J
authors.initials: RJ
authors.lastname: Martin
authors.forename: M A
authors.initials: MA
authors.lastname: Simpson
authors.forename: Y B
authors.initials: YB
authors.lastname: Dong
authors.forename: N
authors.initials: N
authors.lastname: Ali
authors.forename: A H
authors.initials: AH
authors.lastname: Crosby
authors.forename: J F
authors.initials: JF
authors.lastname: Powell
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy / Q000706:statistics & numerical data; D015161:Dementia, Multi-Infarct / Q000175:diagnosis* / Q000235:genetics; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017354:Point Mutation / Q000235:genetics; D011518:Proto-Oncogene Proteins / Q000235:genetics; D000071656:Receptor, Notch3; D011956:Receptors, Cell Surface; D051880:Receptors, Notch; D012867:Skin / Q000473:pathology; D018709:Statistics, Nonparametric
chemical_list: C499374:NOTCH3 protein, human; D011518:Proto-Oncogene Proteins; D000071656:Receptor, Notch3; D011956:Receptors, Cell Surface; D051880:Receptors, Notch