<i>DIAPH1</i> Variants in Non–East Asian Patients With Sporadic Moyamoya Disease
Authors: Adam J. Kundishora, Samuel T. Peters, Amélie Pinard, Daniel Duran, Shreyas Panchagnula, Tanyeri Barak, Danielle F. Miyagishima, Weilai Dong, Hannah Smith, Jack Ocken, Ashley Dunbar, Carol Nelson-Williams, Shozeb Haider, Rebecca L. Walker, Boyang Li, Hongyu Zhao, Dean Thumkeo, Arnaud Marlier, Phan Q. Duy, Nicholas S. Diab, Benjamin C. Reeves, Stephanie M. Robert, Nanthiya Sujijantarat, Amber N. Stratman, Yi-Hsien Chen, Shujuan Zhao, Isabelle Roszko, Qiongshi Lu, Bo Zhang, Shrikant Mane, Christopher Castaldi, Francesc López-Giráldez, James R. Knight, Michael J. Bamshad, Deborah A. Nickerson, Daniel H. Geschwind, Shih-Shan Lang Chen, Phillip B. Storm, Michael L. Diluna, Charles C. Matouk, Darren B. Orbach, Seth L. Alper, Edward R. Smith, Richard P. Lifton, Murat Gunel, Dianna M. Milewicz, Sheng Chih Jin, Kristopher T. Kahle
Journal: JAMA Neurology (2021)

<h3>Importance</h3> Moyamoya disease (MMD), a progressive vasculopathy leading to narrowing and ultimate occlusion of the intracranial internal carotid arteries, is a cause of childhood stroke. The cause of MMD is poorly understood, but genetic factors play a role. Several familial forms of MMD have been identified, but the cause of most cases remains elusive, especially among non–East Asian individuals. <h3>Objective</h3> To assess whether ultrarare de novo and rare, damaging transmitted variants with large effect sizes are associated with MMD risk. <h3>Design, Setting, and Participants</h3> A genetic association study was conducted using whole-exome sequencing case-parent MMD trios in a small discovery cohort collected over 3.5 years (2016-2019); data were analyzed in 2020. Medical records from US hospitals spanning a range of 1 month to 1.5 years were reviewed for phenotyping. Exomes from a larger validation cohort were analyzed to identify additional rare, large-effect variants in the top candidate gene. Participants included patients with MMD and, when available, their parents. All participants who met criteria and were presented with the option to join the study agreed to do so; none were excluded. Twenty-four probands (22 trios and 2 singletons) composed the discovery cohort, and 84 probands (29 trios and 55 singletons) composed the validation cohort. <h3>Main Outcomes and Measures</h3> Gene variants were identified and filtered using stringent criteria. Enrichment and case-control tests assessed gene-level variant burden. In silico modeling estimated the probability of variant association with protein structure. Integrative genomics assessed expression patterns of MMD risk genes derived from single-cell RNA sequencing data of human and mouse brain tissue. <h3>Results</h3> Of the 24 patients in the discovery cohort, 14 (58.3%) were men and 18 (75.0%) were of European ancestry. Three of 24 discovery cohort probands contained 2 do novo (1-tailed Poisson<i>P</i> = 1.1 × 10<sup>−6</sup>) and 1 rare, transmitted damaging variant (12.5% of cases) in<i>DIAPH1</i>(mammalian diaphanous-1), a key regulator of actin remodeling in vascular cells and platelets. Four additional ultrarare damaging heterozygous<i>DIAPH1</i>variants (3 unphased) were identified in 3 other patients in an 84-proband validation cohort (73.8% female, 77.4% European). All 6 patients were non–East Asian. Compound heterozygous variants were identified in ena/vasodilator-stimulated phosphoproteinlike protein EVL, a mammalian diaphanous-1 interactor that regulates actin polymerization.<i>DIAPH1</i>and<i>EVL</i>mutant probands had severe, bilateral MMD associated with transfusion-dependent thrombocytopenia.<i>DIAPH1</i>and other MMD risk genes are enriched in mural cells of midgestational human brain. The<i>DIAPH1</i>coexpression network converges in vascular cell actin cytoskeleton regulatory pathways. <h3>Conclusions and Relevance</h3> These findings provide the largest collection to date of non–East Asian individuals with sporadic MMD harboring pathogenic variants in the same gene. The results suggest that<i>DIAPH1</i>is a novel MMD risk gene and impaired vascular cell actin remodeling in MMD pathogenesis, with diagnostic and therapeutic ramifications.