Quantitative Mapping of Substantia Nigra Iron in Parkinson's Disease and Controls
Phase: PHASE1
Conditions: Parkinson Disease, REM Sleep Behavior Disorder, Healthy
Sponsor: Weill Medical College of Cornell University

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PROTOCOL TITLE: Quantitative Mapping of Substantia Nigra Iron in Parkinson’s Disease (Stages I-IV, REM 
sleep behavior disorder) and Controls 
 
PRINCIPAL INVESTIGATOR: Dr. Alexander Shtilbans, MD, PhD, Weill Cornell Medicine 
IRB Protocol #: 1711018740 
ClinicalTrials.gov Identifier: NCT03675282 
 
Current Version: September 10, 2021 
 
Prior Version Dates: 
Version September 10, 2021 
Version August 4, 2021 
Version May 11, 2021 
Version September 9, 2019 
Version February 2, 2019 
Version November 28, 2018 
Version October 25, 2018 
Version September 26, 2018 
Version June 29, 2018 
Version November 9, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 

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BACKGROUND 
To help the development of  iron chelation as a potential therapy for Parkinson's  Disease  (PD),   
this   study is  designed  to  establish  an  accurate and sensitive Quantitative Susceptibility Mapping 
(QSM)-based Substantia Nigra (SN) iron mapping method. Furthermore, should  trials  of   iron   
chelation   therapy in PD prove that this intervention has clinical effectiveness, an improved 
method to measure SN iron concentration (such as QSM as proposed  herein)  could  become a 
companion Radiological Biomarker for triage and response assessment; and potentially for dose 
modulation to prevent potential over-treatment. We propose a study to assess SN iron changes 
to test the hypothesis that the QSM based iron mapping technique is more sensitive than the 
current R2* method for monitoring nigral iron change in PD patients. Prooxidant iron accumulation 
in the substantia nigra pars compacta  (SNc)  in  the  midbrain  is  one possible reason for SNc 
vulnerable to neurodegeneration. Increased iron in SN of PD patients have been evaluated by 
various MRI methods to be correlated with disease severity, duration, and other patient 
assessments. Longitudinal studies show that iron estimated by MRI progressively increase in PD 
subjects but not in controls. Iron elevation can  cause cell death mediated by oxidative stress. The 
increased iron is located within individual dopaminergic neurons in the PD SNc, which leads to 
the following consequences: 1) The interaction of ferrous iron (Fe(II)) with oxygen (hydrogen 
peroxide) readily generates highly toxic hydroxyl radicals (HO¿) via Fenton chemistry. Post 
mortem PD-affected brains display increased lipid peroxidation, oxidative damage to DNA, and 
lowered levels  of  the  reduced  form of glutathione, which all reflect oxidative stress. 2) Iron can 
impact the aggregation of alfa-synuclein, the major component of Lewy bodies in PD. Alfa-synuclein 
binds to iron, which accelerates its aggregation into fibrils and is consistent with pathological finding 
of enriched iron in Lewy bodies. Alfa-synuclein has also been shown to directly generate hydrogen 
peroxide when  it  aggregates and, in the presence of iron, produces toxic hydroxyl radicals. 3) 
The aggregation of alfa-synuclein in PD can proliferate microglia, and iron can polarize microglia 
to the  pro-inflammatory  M1  phenotype that produces cytotoxic  cytokines,  which is observed in 
the advanced dopaminergic degeneration in symptomatic PD. While noninvasive MRI is sensitive to 
the presence of iron  that  is  paramagnetic,  current MRI methods to quantify iron are highly 
problematic. A commonly used method is the signal decay rate R2*, to be precise, the decay rate 
of the magnitude signal along the data sampling echo time TE in the commonly used gradient 
echo sequence. We have found that R2* suffers from various problems including 1) dependences 
on imaging parameters including voxel size and field strength, 2) blooming artifacts, which are 
particularly  strong at  SNc  that is near the nasal cavity air-tissue interface of strong magnetic 
susceptibility difference, and 3) interfering effects from cellular contents such as membranes, 
proteins (neuromelanin, alpha-synuclein, etc). Our investigations have lead to the physics insight 
to model MRI  signal  dependence on paramagnetic iron, which is the so called forward problem 
from iron to MRI signal phase or field. Accordingly, we have innovated the inverse solution from 
field to iron source, which is termed as quantitative susceptibility mapping (QSM). We are 
performing ex vivo studies to demonstrate that QSM is much more accurate that R2* for measuring 

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iron by comparing with elemental analysis, the gold standard. This in vivo patient project is designed 
to demonstrate that QSM will provide much better image quality and higher sensitivity than R2* 
quantitatively mapping iron in SNc. 
 
STUDY DESIGN 
Prospective, single center trial to determine whether the current R2* iron mapping method for 
measuring nigral iron changes in Parkinson's Disease (PD) can be significantly improved by using 
the Quantitative Susceptibility Mapping (QSM) based iron mapping techniques with the goal of 
validating QSM for potential use in later clinical trials. This study will include six cohorts - 
Parkinson's Disease (PD) Stage I (20 subjects), PD Stage II (20 subjects), PD Stage III (20 subjects), 
PD Stage IV (20 subjects), REM Sleep Behavior Disorder (RBD) (10 subjects), and healthy controls (10 
subjects). Subjects who meet the inclusion and exclusion criteria and whom sign an informed 
consent form will be eligible for participation in this  study and will undergo the following 
assessments regardless of cohort stratification. Screening and Baseline: Subjects will be  seen  in the 
Movement Disorder Clinic within the Department of Neurology at Weill Cornell Medicine, or at 
HSS, or at Cornell Ithaca (other recruiting sites) for an in-office visit which will include review of 
medical history, concomitant medication review, physical exam, urine pregnancy test (females of 
childbearing potential age) and completion of clinical surveys. This visit may be a standard  of  care,  
office  visit, or may be an office visit performed for research purposes. If standard of care, in-office 
neurological assessments have already been performed within three months of study imaging, this 
may be used to satisfy the study baseline/screening and 24 month in office assessments. All subjects, 
whether recruited at WCM or HSS, will receive either a PE2i Positron Emission Tomography (PET) scan 
or DaT single photon emission computed tomogrpahy (SPECT) scan, and Magnetic Resonance Imaging 
(MRI) scan of the brain at WCM. If the subject received a standard of care MRI scan of the brain within 
1 month of  screening, this exam will be utilized to satisfy the baseline requirement for an MRI of 
the brain. However, if a standard of care MRI of the brain was performed either at an outside 
facility or at New York Presbyterian-Weill Cornell Medicine outside the required 1 month window 
to enrollment, the  MRI  of the brain will be repeated at Baseline as performed for research 
purposes. Month 24 (+/- 2 Months): Subjects will  be  seen  in the Movement Disorder Clinic within 
the Department of Neurology at Weill Cornell Medicine, or at HSS for an in-office visit (either 
as a standard of care office visit, or may be an office visit for research purposes) which will include 
review of medical history, review concomitant medications, physical exam,  urine  pregnancy   test   
(females of childbearing potential age), complete surveys; and subjects will receive a repeat PE2i 
PET scan or DaT scan and MRI of the brain at WCM. The following  outlines which procedures are 
considered performed for research purposes vs. performed for standard of care purposes for PD and 
RBD Cohorts: Performed for Research Purposes: PE2i PET Scan or DaT scan performed at Baseline 
and Month 24 visit; MRI of the brain performed at Baseline (only if repeated for research purposes 
as outlined above) and Month 24 visit; Urine pregnancy test for female subjects of child-bearing 
potential age  performed  at  baseline  and  Month 24 visit. Performed for  Standard of Care 
Purposes: Office visit performed at Baseline and Month 24 visit (unless subjects are asked to return 
for an office visit performed for research purposes with the Neurology team at WCM or HSS); 
MRI of the brain performed at Baseline visit; Completion of clinical neurological surveys (e.g. 
UPDRS). Subjects recruited at Cornell Ithaca will have the MRI at the Cornell MRI Facility and may or 
may not have a PE2i PET scan or DaT scan at WCM. Subjects who receive the DaT scan will have to 
take Lugol’s solution before scanning to protect their thyroid. 

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Our primary objective is to establish that Quantitative Susceptibility Mapping (QSM) is more sensitive 
than R2* for nigral iron mapping in monitoring PD iron overload.  
 
Our secondary objective is to evaluate rate of iron accumulation throughout different disease stages. 
1. Unified Parkinson’s Disease Rating Scale (UPDRS) scores to monitor for clinical changes. 2. 
Quantitative PE2i PET scan estimations to monitor for dopaminergic degeneration. 
 
INCLUSION AND EXCLUSION CRITERIA 
Inclusion Criteria: 
1. Idiopathic Parkinson’s Disease, REM sleep behavior disorder subjects without signs of 
Parkinsonism and normal healthy controls.  
a. If tremor is not present, subjects must have unilateral onset and persistent asymmetry 
of the symptoms. 
b. For PD subjects only: age > 30 years  at time of diagnosis of PD with a maximum age of 
100 years old. 
c. Hoehn & Yahr stage < V (if PD) 
2. For PD subjects only: receiving an optimized dopaminergic regimen (i.e., either MAO-B inhibitor, 
a dopamine agonist and/or low doses of L-dopa, with dose change no more frequent than every 
6-months in the course of the study); or medications naïve 
3. No overt anemia, iron deficiency, or other hematological disorders 
4. Deemed healthy and able to undergo MRI and PE2i PET imaging by the site investigator, based 
on screening assessments—medical history, physical examination 
5. For controls and REM sleep behavior disorder subjects only: age 20-80; willing to undergo 
multiple imaging sessions 
6. Signed informed consent form 
 
Exclusion Criteria:  
1. Patient with atypical parkinsonism (such as suspected Progressive Supranuclear Palsy, 
Multiple System Atrophy) and secondary parkinsonism (such as normal pressure  
hydrocephalus,   drug-induced, or vascular parkinsonism)   
2. Patients with uncertainty as to having classical Parkinson's  disease,  such   as   those who 
might have  scans  without  evidence of     dopaminergic     deficits     (SWEDDs) 
3. Presence   of   a   medical   or psychiatric comorbidity that can compromise participation in  
the  study   
4. Patients with clinically significant depression as determined  by  the  Beck  depression score  
>  15    
5. History   of   exposure to  typical  or  atypical  neuroleptics  or any dopamine blocking agent 
within 6 months prior to enrollment  
6. Patients with psychosis/active hallucinations and memory difficulty pre-dating the onset of 
motor symptoms  

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7.  History of brain surgery for PD  
8.  Untreated thyroid disease  
9.  History of  stroke  or  cerebral  vascular  disease 
10. History of  drug  abuse   
11. History of  repeated  head  injury  or  encephalitis 
12.  Positive dementia by DSM IV-R  
13.  Women of childbearing potential who are not surgically sterilized have to use a reliable 
measure of contraception  and have a negative urine pregnancy  test  at the screening  
14. Participation in other investigational drug trials within 30 days prior to screening  
15. Contraindication for receiving MRI imaging such as presence of pacemakers, certain types 
of metallic implants,  severe  claustrophobia,   history of reaction to contrast material, or 
renal insufficiency. 
 
 
DATA AND SAFETY MONITORING PLAN 
To assess both safety and efficacy of PE2i study procedures, intra-imaging monitoring will be performed 
to assess subject safety. In addition, subjects will return for in-office physician visits at designated time 
points (baseline and 24 months) where physical exam, vital check, and adverse events will be assessed 
and tabulated. 
There are no defined stopping rules however,  in  the  event  that  the  FDA, IRB, or other regulatory 
agencies request stoppage, all study activities would be immediately halted. The goal of the study 
is to to establish an accurate and sensitive QSM-based SNc iron mapping method through 
observation only so there is no therapeutic intent and, thus no defined stopping rules. 
Circumstances for subject termination/dropout due to study-related adverse events are highlighted 
in the adverse events-related termination section listed below. 
Adverse events that may cause termination/dropout of a subject: generally, inability to tolerate the 
study procedures, imaging: claustrophobia during imaging studies or inability to obtain venous access. 
Anticipated adverse events and risks of study interventions: 
1. Pe2i scans. Subjects may experience discomfort from lying still on their back for each scan; 
Some people feel claustrophobic in  the  PET  scanner.  If   this   happens the scan will stop 
immediately. PE2i-PET scans are experimental studies  that  may be conducted only for 
medical research purposes. PE2i-PET involves exposure to radiation, and that exposure 
is increased the more often such tests are done. Radiation exposure at certain doses can 
potentially cause cancer. The PE2i tracers are radioactive because one of the atoms 
(Carbon-11) that make up the drug has been man-made in such a way that it will 
spontaneously decompose. When it does, it will give off a type of  radiation  in  the form 
of rays. These special type of rays are a form of radiation that cannot be seen with the 
human eye, but the PET camera has sensors that can detect where it is coming from inside 
your body. These rays will be used to make pictures of the subject's brain. The total amount 

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of radiation that subjects will be exposed to from the PET scans in this study is  a  little  
less  than the amount of radiation exposure allowed for occupational workers over a 
period of one year. There are always theoretical risks associated with exposure to radiation 
of any kind, including the risks of developing cancer and hardening of the arteries. These 
risks are considered within acceptable limits for human subjects who will not personally 
benefit from their participation in the research study.  
2. Allergic reactions. With any drug (radioactive chemical substance used in PE2i PET 
scans), there is a possibility of an allergic reaction. Allergic reactions  most  commonly  
are  mild  such as a rash, cough, dizziness, or fainting, hives, itching, chest tightness, 
shortness of breath or wheezing. Rarely, a more severe and possibly even life-threatening 
reaction can occur, such  as  anaphylaxis (a reaction which may involve shortness of 
breath, swelling or closing of the airway and/or drop in blood pressure). In the event of 
an allergic reaction, medical treatment will be immediately available from the study 
staff. The risks of an allergic reaction from imaging exams in this study are very low. 
3. IV catheter. Before each PE2i PET scan study begins, a catheter will be placed in the 
subject's forearm. Catheter placement may cause bleeding, bruising, redness, swelling 
discomfort, and/or pain at the needle site or dizziness and fainting. The bruising and 
discoloration at the areas where the venous catheters are inserted may last for several 
days after the study. On rare occasions, they may cause clot formation and infection. The 
subject will be instructed to notify the study physician right away if symptoms are 
caused from the IV catheter.  
4. MRI scans. There are no known risks or adverse effects resulting directly from 
exposure to magnetic fields and radiofrequency signals used  in  the  MRI  imaging   other   
than the potential risks  associated with the scanning procedure summarized below: A. 
Claustrophobia. Some subjects may feel claustrophobic in the MR scanner. If this 
happens the study team will stop the scan immediately. B. Metallic Foreign Body Risks. 
Subjects may not be able to undergo MRI scanning if they have pacemaker, or certain 
other implanted electronic or metallic devices. Subjects will be screened for MRI 
contraindications during the screening visit.  
5. DaT scans. The most common side effects of DaT imaging are headache, increased appetite, 
and dizziness. However, it is important for you to know that the injection of DaTscan may 
include risks that cannot be predicted, although for the purposes of this study, it is being used 
in accordance with its FDA approved usage. The insertion of the IV may feel uncomfortable and 
may leave a bruise. You will need to lie very still under the camera for up to 1 hour, which may 
be uncomfortable. The DaT scan included in this study is employed routinely in the care of 
patients with medical conditions. It involves exposure to radiation and that exposure is 
increased the more often such tests are done. Radiation exposure at certain doses can 
potentially cause cancer. Any possible increase in cancer risk associated with participation in 
this study is within acceptable limits for human research subjects. 
 
In order to immediately recognize the adverse events that do occur, appropriate screening will be 
performed, including -physical exam, vitals signs, urine pregnancy test to verify eligibility before 
initiating any study related procedures. On the day of PE2i PET or DaT scan imaging, subject's vital 
signs will be taken and injection-site tolerance will be assessed after the injection of radioactive 
material. Any assessment of adverse events will be documented and reported as necessary. 

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To minimize any negative impact on subjects resulting from study closure or a subject being 
terminated from the study: in the event of premature discontinuation, subjects will receive adequate 
clinical follow-up from their treating physicians in accordance with standard of care follow up 
guidelines. 
 
Appropriate screening will be performed, including physical exam, vital signs, urine pregnancy test to 
verify eligibility before initiating any study related procedures. On the day of PE2i PET or DaT scan 
imaging, subject’s vital signs will be taken and injection-site tolerance will be assessed after the 
injection of radioactive material. Any assessment of adverse events will be documented and reported 
as necessary. 
 
In the event of premature discontinuation, subjects will receive adequate clinical follow-up from their 
treating physicians in accordance with standard of card follow up guidelines.  
Adverse events will be graded on severity, attribution, and expectedness. All AEs whether related 
or not, anticipated or not, will be reported to the IRB. Severity defined as: Mild: the subjects is 
aware of the sign or symptom, but it does not interfere with his/her usual daily activities and/or  
it  is of no clinical consequence. Moderate: the AE interferes with the usual daily activities of the 
subject of it is of some clinical consequence. Severe: the subject is unable to work normally or to carry 
out his/her usual daily activities, and/or AE is of definite clinical consequence. AE's will be reported 
to the WCMC IRB as they occur. According to local requirements, the study team will communicate 
relevant safety information to the appropriate agency(ies), IRB, and/or all active investigators as it 
becomes available. 
 
We will be using a medical monitor. The monitor will be affiliated with WCMC-NYP and is a part of the 
research study. 
 
STATISTICAL ANALYSIS PLAN 
Clinical outcome assessments: The six subject cohorts will be compared to assess differences in 
their clinical evaluations and MRI iron measurements obtained in this study. MRI iron measurements 
will be correlated with clinical evaluations to estimate iron overload effects at baseline visit and 
month 24 visit after enrollment. Also, these MRI iron measurements will be correlated with rate of 
dopaminergic loss if detected by PE2i PET or DaT scan imaging. Statistical analyses: All analyses will 
be performed using a statistical software (SPSS, Chicago, IL). The kappa test will be used to assess 
reader agreements, and covariance analysis (adjusted for baseline differences) to estimate clinical 
outcomes as measured by UPDRS at baseline and 24 Months, and PE2i PET or DaT scans at baseline 
and 24 Months. For non-normally distributed data, the robustness will be checked after log 
transformation. The analysis of variance assumption will be validated by residual analysis, and the 
size   effect will be adjusted for baseline differences. Correlation and logistic regression will be 
performed among various MRI and PE2i PET or DaT scan measurements and other clinical data. The 
longitudinal data will be modeled using the generalized estimating equation (GEE) to assess 
significant change. Paired t-test and ROC curve comparison will be performed to assess differences 
between QSM and R2*. 
 

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