Homozygous mutations are extremely rare in CADASIL.
We report the largest series to date on NOTCH3 homozygous mutation and compare the phenotype to heterozygous patients.
Homozygous C3769T mutation was found in 7 family members, while heterozygous mutation was found in 6 members.
The phenotype of homozygous individuals is within the spectrum of CADASIL, although slightly at the severe end when compared to heterozygotes.
Genetic modifiers and environmental factors may play a role in the severity of the clinical phenotype and imaging features of CADASIL patients.