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Objective  To conduct a clinical study of a family with neurologic symptoms and findings carrying a novel  NOTCH3  mutation and to analyze the molecular consequences of the mutation.    Methods  We analyzed a family with complex neurologic symptoms by MRI and neurologic examinations. Exome sequencing of the  NOTCH3  locus was conducted, and whole-genome sequencing was performed to identify  COL4A1 ,  COL4A2 , and  HTRA1  mutations. Cell lines expressing the normal or NOTCH3 A1604T  receptors were analyzed to assess proteolytic processing, cell morphology, receptor routing, and receptor signaling.    Results  Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary form of cerebral small vessel disease (SVD) and caused by mutations in the  NOTCH3  gene. Most CADASIL mutations alter the number of cysteine residues in the extracellular domain of the NOTCH3 receptor, but in this article, we describe a family in which some members carry a novel cysteine-sparing NOTCH3 mutation (c.4810 G>A, p.Ala1604Thr). Two of 3 siblings heterozygous for the NOTCH3 A1604T  mutation presented with migraine and white matter lesions (WMLs), the latter of a type related to but distinct from what is normally observed in CADASIL. Two other members instead carried a novel COL4A1 missense mutation (c.4795 G>A; p.(Ala1599Thr)). The NOTCH3 A1604T  receptor was aberrantly processed, showed reduced presence at the cell surface, and less efficiently activated Notch downstream target genes.    Conclusions  We identify a family with migraine and WML in which some members carry a cysteine-sparing hypomorphic  NOTCH3  mutation. Although a causal relationship is not established, we believe that the observations contribute to the discussion on dysregulated Notch signaling in cerebral SVDs.

Novel Cysteine-Sparing Hypomorphic NOTCH3 A1604T Mutation Observed in a Family With Migraine and White Matter Lesions