Citation Nr: 0814473 Decision Date: 05/01/08 Archive Date: 05/12/08 DOCKET NO. 04-10 830 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for head injury residuals, including headaches. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Associate Counsel INTRODUCTION The veteran served on active duty from September 1952 to August 1954, including honorable service in the Korean Conflict. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which did not find that new and material evidence had been received to reopen the veteran's claim for service connection. The veteran appealed and in a 2007 decision the Board reopened the claim and remanded it to the RO for further development including a VA examination. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The veteran asserts that his current headaches are a result of his head injury in service in 1953. A September 1953 service medical record reveals that the veteran and a friend were wrestling in a tent when the veteran slipped and hit his head on the floor. He momentarily became unconscious but was roused easily. He seemed to have amnesia for the event, however, and was also found to be disoriented when seen by medical personnel. He did not know the date and although he knew that he was at Ashiya (i.e. Ashiya Air Force Base), he did not know where Ashiya was. He also did not know how he got to the hospital. The diagnostic impression was cerebral concussion and the veteran was admitted to the hospital. In his March 2004 Form 9 the veteran requested that VA secure the hospitalization reports documenting his September 1953 hospital stay for concussion in Ashiya, Japan. He indicated that he was hospitalized with the concussion for approximately 7 days. In a November 2007 medical examination and opinion, a VA neurologist, Dr. F did not find that the veteran's headaches or cerebral changes noted on a recent brain MRI were residuals of his head trauma in service. Dr. F also did not note any other residuals of the veteran's 1953 head trauma. Dr. F indicated, however, that the veteran did not actually incur a concussion in September 1953, as he did not have retrograde or anterograde amnesia for the September 1953 head injury. Given that the service medical records clearly indicate that the veteran was admitted to the hospital after incurring his September 1953 head injury, records of this hospitalization are constructively of record. Additionally, it is necessary to obtain the records to attempt to better clarify the severity of the veteran's head injury in service, as he alleges that he was actually hospitalized for up to an entire week post injury. As there is no indication that the RO attempted to obtain these records, a Remand is necessary so that they can be obtained, if available. After any available records are obtained, the RO should obtain an addendum opinion from Dr. F, which takes into account any 1953 records of hospitalization and also accounts for the September 1953 finding that the veteran did have a concussion with apparent amnesia for the event that brought him into the hospital. Accordingly, the case is REMANDED for the following action: 1. The RO should attempt to obtain any available clinical records of the veteran's September 1953 hospitalization for head injury. If, after all reasonable efforts, such records are determined to be unavailable, the RO should make an appropriate notation in the record. 2. The RO should ask the veteran to identify all sources of treatment or evaluation he has received for headaches or other neurological problems since October 2007 and should secure copies of complete records of the treatment or evaluation from all sources identified. 3. Dr. F, if available, should be asked to provide an addendum medical opinion regarding the etiology of the veteran's headaches, which takes into account any obtained records of the veteran's September 1953 hospitalization for head injury. The opinion should also appropriately account for the September 1953 service medical record findings that the veteran did have a cerebral concussion; that he had apparent amnesia for this head trauma; that he did not know what day it was; and that he did not know how he got to the hospital. Dr. F should then specifically be asked to indicate whether the veteran's headaches or other neurological pathology are at least as likely as not (i.e. 50 percent chance or greater) related to the head trauma in service, diagnosed as a cerebral concussion. The claims file should be made available to Dr. F in conjunction with the provision of his opinion and Dr. F should explain the rationale for the opinion given. 4. If, and only if, Dr. F is not available to provide the addendum opinion, the RO should arrange for a VA neurological examination by an appropriate physician to determine the likely etiology of the veteran's current headache disability, and any other neurological impairment. The veteran's claims folder must be made available to the examiner in conjunction with the examination. Any indicated tests should be performed. The examiner should then provide an opinion whether such disability is at least as likely as not (i.e. a 50 percent chance or greater) related to his head trauma in service. The examiner should explain the rationale for the opinion given. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).