Dynamic Brain Mapping of the Functional Effects of Levodopa on Multiple Cortex-basal Ganglia Circuits in Parkinson ́s Disease
Conditions: Parkinson Disease
Sponsor: Danish Research Centre for Magnetic Resonance

Study Protocol and Statistical Analysis Plan 
 
H-22010296 
 
1 
Title:  
Dynamic Brain Mapping of the Functional Effects of Levodopa 
on Multiple Cortex-basal Ganglia Circuits in Parkinson ́s 
Disease 
 
ID:  
H-22010296 
 
Date:  
October 5, 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study Protocol and Statistical Analysis Plan 
 
H-22010296 
 
2 
STUDY PROTOCOL 
For the sub-study, we aim to recruit 25 PD patients with LID, 25 PD patients without LID, 
and 25 age-matched healthy controls. 
 
Day 1: Clinical and neuropsychological tests 
A neurological examination as well as clinical and neuropsychological tests will be 
performed including Unified Parkinson’s Disease Rating Scale (UPDRS), MDS-UPDRS, 
Unified Dyskinesia Rating Scale (UDysRS), Non-Motor Symptoms Questionnaire & Scale 
for Parkinson’s Disease (NMSQuest & NMSS), Non-Motor Fluctuation Assessment 
(NoMoFA) Questionnaire, Montreal Cognitive Assessment (MOCA), Lille Apathy Rating 
Scale (LARS), Barratt Impulsiveness Scale (BIS-11), Questionnaire for Impulsive-
Compulsive Disorders (QUIP), Major Depression Scale (MDI), Edinburgh Handedness 
Inventory (EHI). 
Total duration of day 1 is 2-3 hours. 
 
Day 2: Structural and functional 3T MRI 
Patients will not take their ordinary morning dose of antiparkinsonian medication before 
arrival. Patients will be rated using the UPDRS, MDS-UPDRS and UDysRS in the pragmatic 
off state (after 12 hours of withdrawal of antiparkinsonian medications). First a 3T T1w and 
T2w sMRI will be performed (10 minutes). Then fMRI in the off state (before levodopa 
intake) will be performed while doing one run of the task (10 minutes). Hereafter the 
participating patients will come out of the scanner to take 150 % of their normal levodopa 
dose as Madopar® Quick. Hereafter the fMRI continues while performing three more runs of 
the task (30 minutes) or until the patient develops LID. After the scan the patients’ 
Parkinson’s symptoms and dyskinesia will be rated using the UPDRS, MDS-UPDRS and 
UDysRS. 
Total duration approximately 2-3 hours including preparation. 
For healthy participants, day 1 and 2 will be combined and they will not take Madopar® 
Quick. Furthermore healthy controls will not be rated with UPDRS, MDS-UPDRS, UDysRS, 
NMSQuest, NMSS, NoMoFa, or QUIP. 
 
 
 

Study Protocol and Statistical Analysis Plan 
 
H-22010296 
 
3 
MRI sequences using 3T Siemens Prisma 
T1-weighted 
Voxel size: 0.9 mm3 
TR: 2700 ms 
TE: 3.7 ms 
TI: 1090 ms 
Flip angle: 9 deg 
 
T2-weighted 
Voxel size: 0.9 mm3 
TR: 2500 ms 
TE: 349 ms 
 
BOLD 
Voxel size: 2.5 mm3 
Number of slices: 62 slices 
Multiband accel. factor 2 
TR = 1800 ms 
TE: 30 ms 
Flip angle: 65 deg 
 
Task description 
During the BOLD fMRI the participants will perform a task. The task is a novel go/no-go 
task developed by our research group. Apart from the motor aspect of the task (left, right, no-
go) it also involves an emotional component of emotional faces in the background, a reward 
component when the participant can win or lose a high or low reward, and reward prospect 
component of two prospects of reward (high or low). Responses are made with MR-
compatible grip-force devices. 
 
Day 3: [18F]PE2I-PET 
Participants will have 175 MBq [18F]PE2I injected via a venous catheter while lying in the 
scanner. Then a clinical [18F]PE2I-PET will be performed. Healthy controls will not 
participate in the PET experiment. 
Total duration approximately 2 hours including preparation. 

Study Protocol and Statistical Analysis Plan 
 
H-22010296 
 
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ASSESS TO CLINCAL DATA 
Participants will be asked for direct access to their electronical medical records from the 
regional database of medical records (Sundhedsplatformen) and the medication database 
(Fælles medicinkort). Access to electronical medical records will be given to personal with 
medical background. The assess to medical records will be included in the informed written 
consent form. 
 
In Sundhedsplatformen the following information will be retrieved: 
1. Medical history regarding PD including time of symptom onset, date of diagnosis, 
information regarding Parkinson symptoms and LID. 
2. Medical history regarding comorbidities which are potential exclusion criteria. 
3. Medical history regarding potential metallic or electrical implants to evaluate the 
safety of participating in the study. 
4. Neuroimaging to confirm the diagnosis of PD including DAT SPECT, PE2I-PET, 
MR-cerebrum. 
5. Imaging to investigate possible electronic or metallic implants e.g., x-ray or MR. 
 
Medical history will be reviewed to make sure that the patient fulfills the inclusion/exclusion 
criteria and to register key data related to Parkinson’s disease. Furthermore, prior imaging 
will be reviewed to also to check that the participants fulfil the inclusion/exclusion criteria 
(no sign of other neurological disease). 
In Fælles medicinkort current list of medication will be retrieved. 
 
QUALITY ASSURANCE PLAN 
All acquired data will be quality assessed. MRI data will be visually assessed during the scan 
and MRI, behavioral, and PET data will be assessed visually and based on quality-assurance 
parameters (e.g. head movement) during preprocessing. 
 
DATA CHECKS 
Will not be performed as only few data are entered manually into registry. Those data will be 
sanity-checked during analysis. 
 
 
 

Study Protocol and Statistical Analysis Plan 
 
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SOURCE DATA VERIFICATION 
Will not be performed as it is not relevant in this study. 
 
RECRUITMENT 
Patient with Parkinson’s disease will be recruited in the ambulatory care setting at the 
Department of Neurology, Bispebjerg Hospital and through private practicing neurologists. 
As part of the clinical assessment relevant PD patients will be asked if they would be 
interested in participating in the study. This can occur as part of the clinical assessment by a 
neurologist or when patients have a PE2I-PET scan. Also, letters with an invitation to 
participate in the study will be sent to patients with PD who are followed in the movement 
disorder clinics of the department. The text of the letters include is a description presentation 
of the research project and a notification that we will make a telephone call within a few 
weeks. Within 1-2 weeks after receiving the letter, we will call the patients to ask if they are 
interested in participating in the study. Spouses accompanying enrolled PD patients at study 
visits will be given the opportunity to participate as healthy controls. Written information is 
handed out or sent to the participants. 
 
Furthermore, Parkinson’s patients and healthy controls will be recruited through 
advertisement. Participants will be recruited from the following websites: 
https://www.sundhed.dk/, http://www.forsoegsperson.dk/, https://www.parkinson.dk/, and 
social media (Facebook, Twitter, and LinkedIn). 
Volunteers will also be recruited via advertisements in local newspapers or posts at sites such 
as culture centres, libraries, locally in the department. 
 
DATA MANAGEMENT 
Confidential documents will be stored in a locked closet. Electronic information that can be 
traced to an identifiable person will be stored on password-protected cluster (Thinlinc) behind 
secure "firewall" in accordance with the Privacy Act and notified to the Danish data agency 
(Datatilsynet) via the Region’s common notification (IDEA0003712/DMND0448431).  
Collected data will be anonymized. The participant's name will never be used in scientific 
publications or presentations. However, participants will, to the extent they wish, be informed 
of their own results. All personally identifiable information will be destroyed (corresponding 
to total anonymity) no later than 10 years after project completion.  

Study Protocol and Statistical Analysis Plan 
 
H-22010296 
 
6 
All sensitive personal data will be stored according to the Danish law on data protection 
”Databeskyttelsesloven” and the General Dataprotection Regulation. 
Participants will receive written information about the handling of data. 
Behavioral and imaging data are stored in the BIDS (Brain Imaging Data Structure, 
bids.neuroimaging.io) standard.  
 
 
STATISTICAL ANALYSIS PLAN 
Preprocessing 
The raw fMRI data will be preprocessed using standard procedures, including motion 
correction, slice-timing correction, spatial normalization, and spatial smoothing. 
fMRIprep will be used for preprocessing. 
 
First level analyses of single-person data 
For each participant and each run, we will create general linear models to model the BOLD 
(Blood Oxygen Level Dependent) response to the task-related events (regressors of interest) 
in each voxel (mass-univariate approach). First-level contrast maps will be generated for each 
participant, comparing the task conditions of interest. We will add a linear time modulation to 
all regressors to model dynamic changes in activation over time. 
 
Contrasts of interest 
1. Motor response: Left, right, no-go 
2. Emotion: Happy, neutral, sad 
3. Reward: High/low reward, high/low loss 
4. Reward context: High, low 
 
Contrasts of no interest 
1. Physiological noise (pulse and respiration) 
2. Movement 
 
 
 
 

Study Protocol and Statistical Analysis Plan 
 
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Second level analyses at group level 
Group Inference: Group-level analysis will involve random-effects models (ANOVA and t-
test) to assess task-related activation across participants. Significance level will be set at 
p<0.05 after correction for multiple comparison. 
 
First and second level analysis will be performed using the freely available software package 
“NILEARN”. 
 
Behavioral data 
Behavioral data will be analyzed in Python. 
 
SAMPLE SIZE ASSESSMENT 
We aim at a beta risk of .8 and an alpha risk of .05 and anticipate a drop-out rate of 20-25 %. 
Furthermore, biological variation in MRI measurements and the signal to noise ratio 
associated with these modalities should be considered. In our previous study (Herz et al., Ann 
Neurol. 2014 Jun;75(6):829-36. doi: 10.1002/ana.24138), we used a similar dynamic 
pharmacological functional MRI approach and a similar task paradigm. In this study, a group 
difference between patients with and without LID was robustly expressed in a sample size of 
13 per group. In prior functional MRI studies comparing patients with PD and healthy 
controls, the necessary number of participants ranged from 10 to 30, depending on the 
scientific question. Therefore, we aim to recruit at least 25 participants per group with 
useable data, so that we can include 25 data sets per group in the between-group analyses. 
 
PLAN FOR MISSING DATA 
In case of missing data, those data will not be imputed. The analysis will be made without the 
missing data. 

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Informed consent for participation in a biomedical research project 
 
Title of the research project: 
Dynamic mapping of changes in brain structure and function in 
Levodopa-induced dyskinesias in Parkinson's disease 
Statement from the research participant 
I have received written and oral information and I know enough about the purpose, method, 
advantages, and disadvantages to agree to participate. 
I know that participation is voluntary and that I can always withdraw my consent without losing my 
current or future rights to treatment. 
I have received a copy of this consent form and a copy of the written information about the project 
for my own use. 
I am aware that I will be informed if abnormal changes are observed in my brain, and that relevant 
information will, if necessary, be forwarded to my general practitioner or relevant 
hospital/department. 
 
Do you want to be informed about the results of the research project and any consequences 
for you?  
Yes _____ (x)  
No _____ (x) 
 
May we contact you again to obtain additional information, should it prove relevant? 
Yes _____ (x)  
No _____ (x) 
 
 

Page 2of 2 
 
May we contact you again with inquiries about participation in other research projects? 
Yes _____ (x)  
No _____ (x) 
Can we post your medical record on the health platform and your medication list on the 
joint medicine card (FMK)? 
Yes _____ (x)  
No _____ (x) 
 
Can we film you during the examinations? – This will not be shared with third parties 
without further consent. 
Yes _____ (x)  
No _____ (x) 
 
Name of participant: 
 
________________________________________________________ 
 
Date: _______________   Signature: 
 
Statement from the experimenter: 
I declare that the subject has received oral and written information about the experiment and has 
had the opportunity to ask me questions. 
In my opinion, sufficient information has been provided for a decision to be made regarding 
participation in the trial. 
 
Name of the person who gave the information: 
 
__________________________________________________________ 
 
Date: _______________   Signature: