Wilhelm Walter is 52 and his wife, Wilhelmina is the same age. Together they own and run a petrol station and live in a three room apartment in a small town. They have no children.
When he was 42, Mr Walter noticed the first signs of Parkinson’s in the form of a tremor and he experienced difficulties with fine motor activities when using the right arm and hand. A neurologist diagnosed Parkinson’s three months after the first symptoms became apparent, starting treatment with Selegiline 10 mg once daily. This did not have the desired effect and Cabergoline 4 mg once daily was added resulting in a partial improvement. Twelve months later levodopa/carbidopa was added and produced an almost complete recovery lasting for nearly three years.
After four years with Parkinson’s Mr Walter developed, rather quickly, motor fluctuations. The “off” periods became increasingly severe; he could walk only with great difficulty and had very limited function in his hands. The “on” periods were often combined with pronounced dyskinesias, including the head. There were no cognitive problems and no depression. Two years ago Mr Walter spent 40% of his waking day “off” and 45% "on" with dyskinesias. Repeated modifications to the peroral therapy had only partial and transient effects. At this time Mr Walter could only work for a few hours per day in the petrol station. His wife had to compensate for this and often worked up to 70 hours per week. In addition she cared for her husband and their social situation became extremely stressful.
In 2006 Mr Walter was admitted to the neurology ward of the university hospital with the aim of starting with an apomorphine pump. Unfortunately, the side effects were so severe, treatment was withdrawn. Bilateral deep brain stimulation (DBS) in the subthalamic nucleus was prepared and performed. The operation took place without complications.
Post-operatively, there was a marked improvement in motor functions. The “off” periods almost disappeared, as did the dyskinesias resulting in a reduction of oral medication. Levodopa/carbidopa from 850 mg daily to 350 mg daily; Cabergoline (8 mg daily) was terminated; pramipexole 0.35 mg three times daily was started and Selegiline (10 mg daily) stopped. The only side effect was depressive mood during the first three months postoperatively.
Following the operation, Mr Walter was able to resume full-time working. He was also able to manage all activities of daily life without support. Health-related quality of life improved significantly according to the PDQ-39 scale.
(This report is based on a real life patient’s case history, with some details being modified.)
