Alzheimer's disease and small vessel ischemic disease frequently co-exist in the aging brain. However, pathogenic links between these 2 disorders are yet to be identified. Therefore we used Taqman genotyping, exome and RnA sequencing to investigate Alzheimer's disease known pathogenic variants and pathways: APOE ε4 allele, APP-Aβ metabolism and late-onset Alzheimer's disease main genomewide association loci (APOE, BIN1, CD33, MS4A6A, CD2AP, PICALM, CLU, CR1, EPHA1, ABCA7) in 96 early-onset small vessel ischemic disease Caucasian patients and 368 elderly neuropathologically proven controls (HeX database) and in a mouse model of cerebral hypoperfusion. only a minority of patients (29%) carried APOE ε4 allele. We did not detect any pathogenic mutation in APP, PSEN1 and PSEN2 and report a burden of truncating mutations in App-Aß degradation genes. the single-variant association test identified 3 common variants with a likely protective effect on small vessel ischemic disease (0.54>oR > 0.32, adj. p-value <0.05) (EPHA1 p.M900V and p.V160A and CD33 p.A14V). Moreover, 5/17 APP-Aß catabolism genes were significantly upregulated (LogFC > 1, adj. p-val<0.05) together with Apoe, Ms4a cluster and Cd33 during brain hypoperfusion and their overexpression correlated with the ischemic lesion size. finally, the detection of Aβ oligomers in the hypoperfused hippocampus supported the link between brain ischemia and Alzheimer's disease pathology.Late-onset sporadic Alzheimer's disease (LOAD) and small vessel ischemic disease (SVID) frequently influence each other and co-exist in the aging brain depicting a clinical, neuroradiological and neuropathological spectrum defined as 'mixed dementia' . Although mixed dementia represents the second common form of dementia in the elderly, as over 45% of LOAD patients neuropathologically diagnosed displayed significant cerebrovascular pathology 1 , the nature and the pathogenic ground at the basis of AD-SVID interaction is poorly understood 2 . APOE ε4 allele is the strongest risk factor for sporadic LOAD 3-5 , however its role in SVID has not been extensively investigated. Common hallmark in small vessel disease is cerebral amyloid angiopathy (CAA), which is caused by excessive deposition of Aβ 40 and 42 on the walls of small vessels 6,7 , responsible both for its ischemic and hemorragic manifestations (SVID and intracerebral hemorrhage [ICH]) 8 . Both rare familial and common sporadic small vessel disease cases pointed to the potential role of APP-Aß dysmetabolism as key pathogenic mechanism underlying CAA small vessel disease subtype. First, autosomal dominant fully penetrant mutations in the secretase domain of APP, APP duplication, CST3 and TTR rare mutations cause familial CAA 9-11 . Second, common variants in IDE and LRP1 have been associated with increased risk of diabetes type 2 and migraine, respectively, that frequently are co-morbidities in SVID patients 12,13 . Third, perivascular and parenchymal Aß deposits have been reported in genetically diagnosed CADASIL patients and vascular ...