Citation Nr: 0209584 Decision Date: 08/09/02 Archive Date: 08/21/02 DOCKET NO. 97-29 523A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to disability compensation under 38 U.S.C.A. § 1151 for abdominal aortic aneurysm with bilateral iliac artery aneurysm and left popliteal aneurysm, with aortoiliac bypass, left frontal intraparenchymal hematoma with multiple intracranial hemorrhages, and status post left frontoparietal craniotomy, claimed as resulting from medical examination and treatment by the Department of Veterans Affairs. REPRESENTATION Appellant represented by: Theodore C. Jarvi, Esq. ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The veteran served on active duty from September 1942 to October 1945. This appeal comes before the Board of Veterans' Appeals (Board) from a July 1997 rating decision of the Phoenix, Arizona, Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision, the RO denied the veteran's claim for disability compensation under 38 U.S.C.A. § 1151 for aneurysms of the abdominal aorta, bilateral iliac arteries, and left popliteal artery, with bypass surgery to address the aneurysms, and for a hematoma and multiple hemorrhages of the brain, with surgery to address those disorders. In a February 2000 decision, the Board denied entitlement to compensation under 38 U.S.C.A. § 1151 for those disorders. The veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). On November 7, 2000, the Court granted a joint motion for remand, and vacated the Board's decision. In May 2001, the Board remanded the case to the RO to develop evidence, and to consider evidence received and changes in the law. The RO substantially completed the actions requested in the Board's remand, continued the denial of the veteran's claim, and returned the case to the Board for appellate review. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. An abdominal aortic aneurysm was detected on VA spine examination in May 1996. 3. An angiogram performed at a VA facility in early June 1996 showed the abdominal aortic aneurysm, bilateral iliac artery aneurysms, and a left popliteal artery aneurysm. 4. The veteran underwent aortoiliac bypass surgery in a VA facility on June 13, 1996. Follow-up treatment and discharge medications included aspirin. 5. The veteran was hospitalized in a VA facility on July 24, 1996, and received treatment for a cerebral hemorrhage. 6. The veteran hospitalized in a VA facility on August 25, 1996, and underwent left frontal craniotomy to address a hematoma. 7. The veteran has additional disability status post abdominal and lower extremity aneurysms, intracranial hemorrhages and hematoma, and VA surgical and medical treatment of those disorders. 8. The veteran's abdominal aorta aneurysm, bilateral iliac artery aneurysms, and left popliteal artery aneurysm did not result from VA examination or treatment. 9. Medical opinions of approximately equal evidentiary weight, from two competent physicians, are in disagreement as to whether anticoagulation due to aspirin prescribed at the VA facility beginning in June 1996 contributed to causing multiple intracranial hemorrhages, and a left frontal intraparenchymal hematoma that necessitated left frontoparietal craniotomy. (CONTINUED ON NEXT PAGE) CONCLUSIONS OF LAW 1. The criteria for entitlement to disability compensation under 38 U.S.C.A. § 1151 for abdominal aortic aneurysm, bilateral iliac artery aneurysms, and left popliteal artery aneurysm, with aortoiliac bypass, are not met. 38 U.S.C.A. § 1151 (West 1991); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 1991 & Supp. 2001); 38 C.F.R. § 3.358 (1995); 66 Fed. Reg. 45620 et seq. (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)). 2. Multiple intracranial hemorrhages, and a left frontal intraparenchymal hematoma, status post left frontoparietal craniotomy, were a result of VA medical treatment. The veteran is entitled to disability compensation under 38 U.S.C.A. § 1151 for those disorders. 38 U.S.C.A. § 1151 (West 1991); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 1991 & Supp. 2001); 38 C.F.R. § 3.358 (1995); 66 Fed. Reg. 45620 et seq. (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist When the Board denied the veteran's claim in the February 2000 decision (since vacated), the Board found that the claim was not well grounded. The joint motion for remand that the Court granted in November 2000 directed the Board to consider and explain whether the Board had properly found the claim to be not well grounded. On November 9, 2000, the President signed into law the Veterans Claims Assistance Act (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West Supp. 2001). Regulations implementing the VCAA were published in August 2001. 66 Fed. Reg. 45620 et seq. (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)). A major provision of the VCAA, significant in addressing the veteran's case, is the elimination of the requirement that a claimant for VA benefits submit a well-grounded claim. In the May 2001 remand, the Board instructed the RO to consider and fulfill the requirements of the VCAA. In an April 2002 supplemental statement of the case (SSOC), the RO listed the provisions of the VCAA and its implementing regulations. In addition to eliminating the requirement of a well-grounded claim, the VCAA and its implementing regulations provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim; although VA is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. 38 U.S.C.A. §§ 5103A, 5107(a) (West Supp. 2001); 66 Fed. Reg. 45620, 45630-31 (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.159(c)-(d)). VA's duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103A(d) (West Supp. 2001); 66 Fed. Reg. 45620, 45630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.159(c)(4)). The new law and regulations also include new notification provisions. Specifically, they require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary, that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 U.S.C.A. § 5103 (West Supp. 2001); 66 Fed. Reg. 45620, 45630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159(b)). The record reflects that the veteran has received the degree of notice which is contemplated by law. Specifically, VA provided the veteran and his representative with the appealed July 1997 rating decision, an October 1997 statement of the case (SOC), the Board's later-vacated February 2000 decision, the joint motion for remand, the Court's order granting that motion, the Board's May 2001 remand, and an April 2002 supplemental statement of the case (SSOC). These documents together relate the law and regulations, including the VCAA and its implementing regulations, that govern the veteran's claim for compensation under 38 U.S.C.A. § 1151. The documents list the evidence considered, and the reasons for the determinations made regarding the claim. The record also discloses that VA has also met its duty to assist the veteran in obtaining evidence necessary to substantiate his claim. The claims file contains his service medical records and relevant VA and private medical records. In a May 2001 remand, the Board instructed the RO to obtain records of the veteran's medical treatment since 1996. The Board instructed the RO to provide VA neurological and vascular examinations and obtain opinions regarding the likely relationship between the veteran's current conditions and VA medical treatment that he has received. The Board also instructed the RO to readjudicate the claim, and provide an SSOC if the claim remained denied. The RO obtained recent private medical records. The RO obtained an opinion from a VA physician who had reviewed the veteran's claims file. That physician wrote that the veteran was severely disabled, and that having the veteran come to a VA facility for examination would cause the veteran undue hardship and expense, and would not be likely to change the physician's opinion regarding the veteran's claim. The RO provided an SSOC reflecting consideration of the newly received evidence together with the previously considered evidence. Although the RO obtained a medical opinion without scheduling examinations of the veteran, the Board finds that the evidence in the claims file, including private and VA medical opinions, is sufficient to reach a decision on the veteran's claim. Therefore, the Board is satisfied that VA has fulfilled its duties both to notify and to assist the veteran in this case. Accordingly, the issue of entitlement to compensation under 38 U.S.C.A. § 1151 is ready for appellate review. II. Entitlement to Disability Compensation under 38 U.S.C.A. § 1151 The veteran is seeking disability compensation under 38 U.S.C.A. § 1151 for abdominal aortic aneurysm with bilateral iliac artery aneurysm and left popliteal aneurysm, with aortoiliac bypass, left frontal intraparenchymal hematoma with multiple intracranial hemorrhages, and status post left frontoparietal craniotomy. The veteran claims that each of these disorders resulted from VA medical examination or treatment. Federal statute, at 38 U.S.C.A. § 1151, and regulations, at 38 C.F.R. § 3.358, govern the circumstances under which VA must pay disability compensation to a veteran for disability or aggravation of disability suffered as a result of VA medical examination or treatment. The law controlling compensation under those circumstances has undergone changes in recent years. It is necessary to determine which version of the law applies in the veteran's case. Prior to the recent changes in the law, 38 U.S.C.A. § 1151 provided that VA would pay disability compensation for additional disability resulting from injury or aggravation of injury as a result of VA medical treatment or examination, provided that the injury or aggravation of injury was not the result of the veteran's own willful misconduct. See 38 U.S.C.A. § 1151 (West 1991). The regulations at 38 C.F.R. § 3.358 included a provision that compensation was not payable for the contemplated or foreseeable results of approved medical care, unless it was shown that the additional disability resulted from carelessness, negligence, or other fault or accident on the part of VA. See 38 C.F.R. § 3.358(c)(3) (1991). In Gardner v. Derwinski, 1 Vet. App. 584 (1991), the Court of Appeals for Veterans Claims (Court) invalidated 38 C.F.R. § 3.358(c)(3), the regulation that provided that fault or accident on the part of VA was necessary for a veteran to be awarded compensation under 38 U.S.C.A. § 1151. The Court held that 38 C.F.R. § 3.358(c)(3) was inconsistent with the plain meaning of 38 U.S.C.A. § 1151, and that the regulation exceeded VA's authority. The Court's decision in Gardner was affirmed by the United States Court of Appeals for the Federal Circuit (Court of Appeals) in Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993). The Court of Appeals decision was then appealed to the United States Supreme Court (Supreme Court). The Supreme Court affirmed the decisions of the Court and the Court of Appeals. See Brown v. Gardner, 115 S. Ct. 552 (1994). In order to conform the regulations to the Supreme Court's decision, on March 16, 1995, VA published amended regulations deleting the fault or accident requirement from 38 C.F.R. § 3.358. Later, effective October 1, 1997, 38 U.S.C.A. § 1151 was amended to reincorporate a fault requirement. See Pub. L. 104-21, Title IV, § 422(a), Sept. 26, 1996, 110 Stat. 2926 (codified at 38 U.S.C.A § 1151(a)(1) (West 1991 & Supp. 1997)). In pertinent part, the amendments established a fault requirement similar to that in the provision that had been stricken from 38 C.F.R. § 3.358. In this case, the veteran's claim for disability compensation pursuant to 38 U.S.C.A. § 1151 was filed in February 1997, before the effective date of the amended 38 U.S.C.A. § 1151 that reincorporates a fault requirement. Congress specifically provided that the amendments to 38 U.S.C.A. § 1151 would be applicable to all claims filed on or after October 1, 1997. See Pub. L. 104-21, Title IV, § 422(a), Sept. 26, 1996, 110 Stat. 2926 (codified at 38 U.S.C.A § 1151(a)(1) (West 1991 & Supp. 1997)). Therefore, the revised statute is not applicable to the veteran's claim. See also VAOPGCPREC 40-97 (December 31, 1997); Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Accordingly, the Board will consider the veteran's claim under the versions of the statute and regulations that were in effect after the fault or accident requirement under 38 C.F.R. § 3.358(c) was deleted, and before 38 U.S.C.A. § 1151 was amended to reincorporate a fault requirement. Specifically, the versions of those statutes and regulations that apply to the veteran's claim are 38 U.S.C.A. § 1151 (West 1991) and 38 C.F.R. § 3.358 (1995). Under those versions, a veteran is entitled to compensation for additional disability if the additional disability resulted from VA medical treatment or examination, as long as the additional disability is not the result of willful misconduct by the veteran. There need not have been fault, negligence, or accident by personnel at the VA facility for compensation to be warranted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 1991 & Supp. 2001). The veteran's contentions were initially presented in a March 1997 statement prepared by the veteran's wife, and marked and notarized as acknowledged by the veteran. The veteran was unable to sign due to paralysis. The veteran essentially contends that he is entitled to compensation for aneurysms in abdomen and legs, for bleeding in the brain, and for the residuals of artery and brain surgeries, because those conditions were caused by VA examination and treatment. The March 1997 statement indicates that an aneurysm of the aorta was diagnosed in a May 1996 VA examination of the veteran, and that he was strongly urged to have surgery to correct the aneurysm. The statement indicates that the veteran underwent surgery in June 1996 at the VA Medical Center (VAMC) in Tucson, Arizona. The statement asserts that he later underwent brain surgery, and that evidence of past bleeding of the brain was discovered during the brain surgery. The statement asserts that the evidence of past bleeding of the brain links the bleeding in the brain to the June 1996 surgery at the VAMC. The statement notes that the veteran subsequently suffered a stroke, and continued in VA treatment after the stroke. In October 1945, the veteran submitted a claim for compensation for a back disorder, described as compression of the spinal column, claimed as incurred as a result of back injury during his 1942 to 1945 service. In a December 1945 rating decision, the Kansas City, Missouri, RO denied service connection for a back disorder, finding that no residuals of injury had been found on the most recent examination. The claims file contains records of private medical treatment of the veteran in 1980 to 1982 for pain in the neck and arms. X-rays revealed degenerative disc disease. A March 1982 treatment record reflects the veteran's report of an injury that had occurred nine years earlier, when a 150-pound set of shelves had fallen onto the top of his head. The veteran reported that pain following that injury had eventually resolved, but that, since 1980, he had again been experiencing severe pain in his neck and right upper extremity. The veteran had cervical spine surgery, with anterior cervical diskectomy and fusion of the C4-C6 vertebrae, in March 1982. In October 1983, the United States Social Security Administration (SSA) found that the veteran was disabled for SSA purposes, due to a cervical spine disability, status post surgery, and vertebral artery insufficiency, with manifestations including dizziness and marked restriction of cervical spine motion. In March 1996, the veteran submitted a new claim for service connection for a back disorder. On May 13, 1996, the veteran had a VA examination at the Tucson VAMC. A physician who performed a spine examination noted that the veteran might have had some seizure activity, because the veteran was taking Dilantin and Phenobarbital. The physician noted that the veteran was a little vague about that history. The physician also noted that the veteran was a borderline diabetic. X-rays of the veteran's spine revealed calcification of the abdominal aorta, with an aneurysm. The radiologist recommended follow-up. The examining physician indicated that the veteran would be seen in vascular surgery to address the aneurysm of the abdominal aorta. Treatment records from the Tucson VAMC reflect that an angiogram performed on June 5, 1996, revealed an intrarenal aortic aneurysm that extended down into the proximal iliac arteries, and a left popliteal arterial aneurysm. The veteran was admitted to the Tucson VAMC on June 12, 1996, for surgery to address the aneurysms. Prior to surgery, the veteran was described as asymptomatic. A report of the veteran's medical history included a questionable history of a seizure disorder. It was noted that the neurology service at the VAMC had seen the veteran, had treated him empirically with Dilantin and Phenobarbital, and had cleared him for surgery. The veteran had surgery on June 13, 1996, and aortobiiliac bypass was performed. He did well postoperatively. He was discharged from the hospital on June 18,1996, with discharge medications including the medications he had taken prior to surgery, plus Percocet and enteric- coated aspirin. On July 25, 1996, the veteran was admitted to the Tucson VAMC with a two day history of headache and altered mental status. It was reported that the veteran had been treated at a private hospital three years earlier, for hyperglycemia, and that he had had poorly documented seizures at that time, and had been placed on Phenobarbital and Dilantin. It was reported that the veteran had continued on the antiseizure medications since then, and had not had any additional seizure activity. At the VAMC, neurological testing including electroencephalogram (EEG) showed left temporofrontal slowing. A right frontal brain hemorrhage was diagnosed. The veteran was discharged to home on August 8, 1996. The veteran was readmitted to the VAMC on August 25, 1996. It was reported that the veteran had experienced about ten minutes of shaking of the upper and lower extremities, and that the veteran had then fallen and hit his head on a wall, damaging the wall. The veteran was brought in for emergency treatment. A CT scan of his head showed a right frontal hyperdensity and a mild subarachnoid hemorrhage in the vertex. During his hospitalization, he was noted to be aphasic and hemiplegic on the right side. The treating physician's initial impression was a mild traumatic subarachnoid hemorrhage, that might be superimposed on amyloid angiopathy. A follow-up CT scan showed a large hemorrhage and a hematoma in the left frontal area. The veteran underwent surgery, a left frontoparietal craniotomy and evacuation of the intracerebral hematoma. Another follow-up CT scan showed a subsequent hemorrhage in the right parietal area. The veteran was discharged from neurosurgery to the neurogeriatic unit on September 12, 1996. At that time, the treating physician reported that the veteran was status post spontaneous bleeds in the brain. The physician noted that evacuation of a bleed had been followed by another spontaneous bleed. The physician reported that a pathology report had indicated amyloid deposits consistent with the bleeding problem. VA records reflect that the veteran received inpatient treatment in the VA nursing home care unit from September 1996 until December 1996. In September 1996, the impression was multiple intracranial hemorrhages due to amyloid angiopathy. An October 1996 neurology note reflects by history that the amyloid component had been proven in August 1996 by biopsy. An October 1996 CT scan revealed left frontal and right temporal hematoma. There was residual vasogenic edema within the white matter of the frontal lobes bilaterally, as well as within the right posterotemporal lobe. The impression was interval resolution of the intraparenchymal hematomas, residual vasogenic edema, and interval resolution of the intraparenchymal air within the left frontal lobe. In November 1996, the veteran had seizure activity, and sustained a new left temporal hematoma. His family was informed that he would continue to have hemorrhages. November 1996 CT scans reflect amyloid angiopathy, and multiple intracranial hemorrhages, with progressive weakness, rule out increasing edema versus new bleed. The clinical findings reflect extensive damage to both cerebral hemispheres due to prior intracerebral hematoma, secondary to amyloid angiopathy. The impression included, inter alia, a new focal parenchymal hemorrhage in the periphery of the left temporal lobe, most likely secondary to amyloid angiopathy. The report of a December 1996 CT scan noted a history of four previous intracranial hemorrhages, presumed to be related to amyloid angiopathy. The examiner noted that no acute hemorrhage or infarct was identified, and that there was no evidence of any other acute intracranial abnormalities. The examiner noted prior intracerebral hemorrhages, as well as multiple foci encephalomalacia. The impression was that there was no CT scan evidence of an acute intracranial process. The veteran was admitted to the VAMC in February 1997, reportedly from private care at the Villa Campana Nursing Home. He was admitted following a three week history of increased lethargy and unresponsiveness, and a one week history of inability to eat. The VAMC treatment report notes the veteran's history of abdominal aorta aneurysm and iliac artery bypass surgery, right front intracranial hemorrhage, and left frontal craniotomy with evacuation of intracerebral hematoma. The veteran received treatment in the VAMC for urinary tract infection and phenytoin toxicity. Medical records reflect that the veteran has continued to receive private nursing home care, at Villa Campana from February 1997 to May 1998, and since May 1998 at Valley Health Care. In December 1998, Herbert W. Kohl, M.D., reported that the veteran had recently had two seizures, and that the seizures were new symptoms for the veteran. Dr. Kohl indicated that the veteran was becoming progressively weaker, and that he was expected to require nursing home care for the foreseeable future. In November 2000, private neuro-radiologist Craig N. Bash, M.D., reported that he had reviewed the veteran's claims file. Dr. Bash discussed numerous specific findings and notations in the claims file, and explained his conclusions. He provided the opinion that the veteran's spontaneous intracranial hemorrhage of July 1996 had been "a direct secondary result" of the veteran's June 1996 VA treatment, including the abdominal aortic aneurysm surgery, a subsequent bland infarct, and anticoagulation. He wrote that this opinion was supported by an August 1996 note in the veteran's treatment records that indicated that the spontaneous bleed was aggravated by the use of aspirin. He opined that the veteran's August 1996 intracranial hemorrhage was a direct result of his VA treatment, as it was likely that the hemorrhage was due to a seizure, fall, and head trauma due to low levels of Dilantin, in conjunction with anticoagulation and amyloid angiopathy. Dr. Bash concluded, "It is my impression that this patient's first two brain hemorrhages and surgical decompression due to VA treatment are the direct cause of his current severe disabilities." In January 2002, VA physician Andrew Cortez, D.O., wrote that he had reviewed the veteran's claims file, including Dr. Bash's opinion. Dr. Cortez indicated that he had strong disagreement with Dr. Bash's opinion. He stated that there was no evidence that the veteran had had a bland infarct. He noted that there was no evidence of central nervous system sequelae when the veteran was discharged from the VAMC following the June 1996 surgery. He asserted that placing the veteran on aspirin was consistent with the standard of care, at the time and presently. He opined that aspirin had not caused the veteran's hemorrhages. He noted that the veteran had been found to have amyloid angiopathy, which is associated with spontaneous hemorrhages. He stated that there was no evidence that the veteran's August 1996 fall had been due to a seizure, and noted that there was no evidence that clearly established that the veteran had ever had a seizure disorder. Dr. Cortez concluded that the veteran had tolerated his June 1996 abdominal aortic aneurysm surgery without any apparent consequence, and that his intracranial hemorrhages were spontaneous and the result of amyloid angiopathy, which was a consequence of his age. In his statement, Dr. Cortez asserted that Dr. Bash's statements were "speculation only." Dr. Cortez wrote of Dr. Bash, "His expertise is in radiology yet he provides no convincing radiographically based evidence for his 'post- operative bland infarct' theory." In May 2002, Theodore C. Jarvi, the veteran's attorney, noted that Dr. Bash's résumé, which had been submitted with his opinion statement, showed that his training and experience was as a neuro-radiologist. In June 2002, Mr. Jarvi wrote that Dr. Cortez's résumé showed that he was an osteopathic internist who had been practicing medicine for about five years, and who was currently serving in an administrative capacity. The résumés of both Dr. Bash and Dr. Cortez are associated with the veteran's claims file. The résumés show that each doctor has completed medical education and training, Dr. Bash in neuroradiology, and Dr. Cortez in internal medicine. The Board finds that both doctors are competent to review medical records and provide medical opinions. As noted above, under the statute and regulations that apply to the veteran's claim, he is entitled to compensation for additional disability if the additional disability resulted from VA medical treatment or examination, as long as the additional disability is not the result of willful misconduct by the veteran. There need not have been fault, negligence, or accident by personnel at the VA facility for compensation to be warranted. See 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. § 3.358 (1995). The aneurysms and brain bleeds that are the subjects of the veteran's claim produce additional disability that was not shown prior to examination and treatment of the veteran in 1996. There is no contention or evidence of willful misconduct by the veteran. Therefore, compensation is warranted if additional disability is a result of VA medical examination or treatment. With regard to the aneurysms of the abdominal aorta, bilateral iliac arteries, and left popliteal artery, evidence of the aneurysms was discovered in the May 1996 VA examination, and in follow-up diagnostic imaging. There is no medical evidence, finding, or opinion that the 1996 VA examination and diagnostics in any way caused or resulted in the development of the aneurysms that were found at that time. The statements in support of the veteran's claim do not indicate that there is any medical evidence of such a connection. The contention that is addressed by medical evidence and opinion is that the June 1996 VA surgery to address the aneurysms, and follow-up medications, including anticoagulants, caused or contributed to one or more of the episodes of brain bleeding that were found in July 1996 and the following months. This question is addressed by medical opinions that reach conflicting conclusions. Dr. Bash opines that anticoagulation provided in the course of the VA treatment, in combination with amyloid angiopathy, resulted in the July 1996 and August 1996 brain hemorrhages. In his written opinion, Dr. Bash provided copious references to documentation of the course veteran's disorders and recuperation. He gave a very detailed explanation of the reasons and bases for his opinions. Dr. Cortez opines that the veteran's brain hemorrhages were caused by amyloid angiopathy, without any link to the June 1996 surgery or medication prescribed following the surgery. For purposes of this decision, it does not matter whether the use of aspirin was the advisable action in the veteran's case, only whether that medication or other aspects of VA treatment can be said to have resulted in the brain hemorrhages. The Board finds that each doctor has given well-reasoned and well-supported arguments for his conclusions. The evidence in this case does not present a basis to find the opinion of either doctor clearly more convincing than the opinion of the other. The Board concludes that the evidence as to whether the brain hemorrhages were the result of VA treatment is approximately balanced. Giving the benefit of the doubt to the claimant, as required by 38 U.S.C.A. § 5107, the Board grants the veteran's claim for entitlement to disability compensation under 38 U.S.C.A. § 1151 for left frontal intraparenchymal hematoma, multiple intracranial hemorrhages, and status post left frontoparietal craniotomy. ORDER The veteran's claim of entitlement to disability compensation under 38 U.S.C.A. § 1151, for abdominal aortic aneurysm, bilateral iliac artery aneurysms, and left popliteal artery aneurysm, with aortoiliac bypass, is denied. The veteran's claim of entitlement to disability compensation under the provisions of 38 U.S.C.A. § 1151, for left frontal intraparenchymal hematoma, multiple intracranial hemorrhages, and status post left frontoparietal craniotomy, is granted. DEBORAH W. SINGLETON Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.