Smooth Muscle Dysfunction Drives Cerebrovascular Reserve Failure and End-Organ Brain Injury

BackgroundFailure of cerebrovascular reserve is a fundamental determinant of ischemic vulnerability, yet the mechanisms by which vascular smooth muscle dysfunction compromises reserve and predisposes the brain to injury remain incompletely defined. We therefore tested whether a pathogenic smooth muscle mutation produces a baseline failure of cerebrovascular reserve sufficient to render the brain vulnerable to hypoperfusion, even in the absence of fixed arterial occlusion. MethodsWe examined cerebrovascular structure, hemodynamics, and reserve in a genetically defined mouse model of ACTA2-associated multisystemic smooth muscle dysfunction syndrome with systemic or brain-restricted expression of the mutant allele. Cerebral artery morphology was assessed using magnetic resonance angiography and black ink angiography. Vascular smooth muscle phenotype was evaluated by immunohistochemistry and proliferation assays. Blood pressure reactivity and cerebral blood flow (CBF) were measured simultaneously using femoral arterial catheterization and laser speckle flowmetry during vasoactive challenges and controlled hypotension. Cerebrovascular stress responses were tested using unilateral common carotid artery occlusion. Downstream brain effects were assessed by histology, resting state functional connectivity imaging, and behavioral testing. ResultsImpaired smooth muscle contractility drove rectification and narrowing of major cerebral arteries, downregulation of contractile markers, and increased vascular cell proliferation. These structural changes produced a distinct physiological phenotype: mutant mice exhibited blunted vasoreactivity, diminished spontaneous vasodynamic activity, and a downward shift in the blood pressure-CBF relationship across a wide range of arterial pressures, consistent with loss of cerebrovascular reserve. As a result, CBF was reduced at baseline and could not be maintained during hypotension or acute vascular stress. During carotid occlusion, mutant mice showed impaired compensatory perfusion, greater physiological instability, and worse behavioral outcomes. Chronic reserve failure coincided with white matter loss, reduced neuronal density, disrupted large-scale functional connectivity, and deficits in locomotion, anxiety-related behavior, and working memory. ConclusionsPathogenic smooth muscle dysfunction caused by ACTA2 mutation produces a baseline failure of cerebrovascular reserve that renders the brain vulnerable to hypoperfusion and stress-induced ischemic injury. These findings establish cerebrovascular reserve failure as a central physiological mechanism linking vascular dysfunction to end-organ brain injury and identify reserve preservation as a critical, potentially actionable determinant of brain health in hypotension-prone vascular disease. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABS- ACTA2 smooth muscle dysfunction produces baseline cerebrovascular reserve impairment, with reduced cerebral blood flow and a downward-shifted pressure-flow relationship in the absence of critical large-vessel occlusion. - Vascular tone dysregulation is coupled to end-organ brain injury, including white matter and neuronal loss, disrupted functional connectivity, and behavioral deficits. - The results support complementary disease mechanisms in ACTA2 vasculopathy: baseline reserve limitation and injury-provoked occlusive remodeling. Clinical Implications- Patients with ACTA2 vasculopathy may be vulnerable to ischemic brain injury during hypotension or systemic stress despite the absence of critical stenosis or occlusion on routine imaging. - Peri-procedural and acute-care management should emphasize preserving perfusion pressure and cerebrovascular reserve (e.g., during anesthesia, dehydration, or systemic illness). - More broadly, cerebrovascular reserve is a clinically relevant, potentially modifiable determinant of brain health in hypotension-prone vasculopathies and conditions characterized by impaired vascular reactivity.