Citation Nr: 1126838 Decision Date: 07/19/11 Archive Date: 07/29/11 DOCKET NO. 10-00 285A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for the residuals of a stroke and seizure, to include as secondary to service-connected coronary artery disease and hypertension. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD R. Erdheim, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1965 to November 1967, from August 1976 to February 1978, and from April 1978 to August 1981. This matter comes before the Board of Veterans' Appeals (Board) from a July 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for the residuals of a stroke and seizure, to include as secondary to the service-connected coronary artery disease and hypertension. The appeal is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. REMAND Additional development is necessary prior to further disposition of the claim. The Veteran contends that the stroke and associated seizures from which he suffered in April 2007 are related to the heart surgery he underwent in February 2007. He also contends that the stroke and seizure were related to years of taking an anticoagulant medication for his peripheral vascular disease or were otherwise related to his longstanding service-connected coronary artery disease and hypertension. The Veteran has suffered from a number of disabilities since his separation from service and for which he is in receipt of disability benefits. Because those disabilities are pertinent to the Veteran's current contentions, a brief summarization of his service-connected disabilities appears pertinent to the remand. While in service, in 1966, the Veteran sustained a low back injury when he was run over by a truck. In January 1981, after experiencing intermittent low back pain and paresthesias of the lower extremities for approximately twenty years, he was admitted to the hospital for a lumbar laminectomy. Following the surgery, he experienced numbness in the right foot and leg. Despite follow-up surgery to remove debris, his right leg pain and weakness continued to worsen. The diagnosis was peroneal nerve palsy. On a January 1983 employment disability evaluation, the Veteran reported weakness in both legs from the level of the hips. He had foot drop on the right and atrophy of the right leg muscles. In February 1983, the Veteran experienced a myocardial infarction for which he was treated medically. A May 1984 VA examination revealed a history of hypertension, well-controlled, and a history of chest pain with possible myocardial infarction and abnormal EKG. In June 1984, the Veteran's private physician stated that he suffered from hypertriglyceridemia, an inherited disease, that could cause arteriosclerosis. On June 1988 VA examination, the Veteran reported that all extremities, his hands and legs, were numb and weak. He could not use crutches because his hands could not grip the handles. He generally used a wheelchair. Physical examination resulted in the diagnosis of generalized polyneuropathy of all extremities. In June 1989, the Veteran's private physician found that the Veteran had very widespread inflammatory arthritis, particularly in the small joints in the hands, wrists, and elbows. He also suffered from a severe neurological deficit in the lower limbs. The use of crutches was causing an inflammation of his arthritis. In February 1992, August 1992, and October 1992, the Veteran underwent surgeries for an abdominal aortic aneurysm and bilateral popliteal aneurysms of the legs, below the knees. It was noted on admission that he suffered from rheumatoid arthritis, peripheral neuropathy, and hypertension. In October 1992, he had continuing complaints of numbness and cold analgia at the right saphenos nerve in the right leg. On December 1993 and January 1994 VA examinations, the Veteran's lost left foot dysfunction was determined to be related to peripheral neuropathy and unusual weight bearing on the extremity. He was diagnosed with fibromyalgia, hyperlipidemia, and degenerative joint disease. June 1994 addendum opinions concluded that the Veteran had suffered from hypertension since 1977 and coronary artery disease since his acute myocardial infarction in 1983. In September 1994, X-ray examination revealed mild degenerative changes in the lumbar and cervical spine, and in the shoulder joints. He continued to suffer from rheumatoid arthritis characterized by symmetrical synovitis. The Veteran was wheelchair bound due to his chronic pain and inability to use his legs. On November 1994 VA examination, it was concluded that the Veteran was starting to suffer from impaired arterial circulation of the right lower extremity, accompanied by elevated triglycerides, first documented in June 1982. On May 1996 VA examination, the Veteran reported that his legs were "useless." He had numbness in both arms and diminished grip strength. He had neuropathy of both lower extremities. He was diagnosed with carpal tunnel syndrome of both upper extremities. He had been diagnosed with diabetes two weeks previously. In October 1997, the Veteran underwent cardiac catherization which showed two-vessel disease with a chronically occluded right coronary artery and 75 percent stenosis in the first diagonal and mild left ventricular dysfunction. In February 1998, one of the Veteran's diagnoses included history of peripheral vascular disease status post femoral-popliteal times two right, time one left with aneurysm repair. He also had a history of stable angina, well controlled on nitrates, coronary artery disease, hypertension, decreased left ventricular function, hyperlipidemia, hypertriglyceridemia, and diabetes. VA treatment records dated in June 2001 show that the Veteran had severe peripheral vascular disease maintained on Coumadin. His inflammatory polyneauropthy was controlled with Methotrexate. On September 2002 VA examination, the Veteran reported that his hands sometimes locked up and he dropped objects. When walking, he was observed to drag both feet on the ground, with diffuse atrophy on the right side. He had normal musculature in the upper extremities. There was motor weakness in all extremities of unclear etiology. On diabetic examination, insulin therapy was anticipated for inadequately controlled diabetes on Glucophage. VA treatment records show that in January 2006, the Veteran's mobility dysfunction did not clearly correlate with his motor deficits. He had an unusual, proximal intentional tremor. In January 2007, the Veteran reported a worsening of dyspnea over the previous year that had made it so that just standing would bring on significant symptoms. He was not always compliant with his CPAP machine and oxygen prescribed for his sleep apnea. Repeat cardiac catherization revealed severe three-vessel coronary artery occlusive disease with mildly diminished left ventricular dysfunction. A coronary artery bypass graft was discussed. In February 2007, he underwent coronary artery bypass surgery. On March 2007 VA examination, the Veteran reported that post surgery, he had had one episode of angina that was relieved with nitroglycerin. A recent post-operative echocardiogram showed left ventricular hypertrophy with mild left ventricular dysfunction in segmental wall motion. He also had mild mitral regurgitation and mild tricuspid regurgitation. A March 2007 private record shows the Veteran's report that when he awoke from heart surgery, he had a painful left arm and shoulder. He had weakness and discomfort in his hand and had his hand in an ulnar grip posture. The symptoms were thought to be either a stretch injury upper trunk brachial plexopathy or possibly cervical radiculopathy. An April 2007 electromyogram was interpreted to suggest a tourniquet injury above the elbow because of the history of a vein graft harvest during surgery. An April 2007 MRI of the cervical spine showed multilevel spondylosis and spondyloartheopathy. In April 2007, the Veteran reported to the emergency room with a report of having a consistent headache for approximately one week. He denied any blurred vision, difficulty with speech or memory, or with motor function. He denied any dyspnea. He had not had a traumatic event such as a fall or any head trauma. Since heart surgery, he had noticed marked improvement in his lower extremity discomfort and strength. It was noted that he was on multiple blood thinners. MRI showed an acute left subdural hematoma and small acute and subacute subdural hematomas in the anterior right frontal region. The impression was symptoms of congestive heart failure, with evidence of a subdural hematoma, likely secondary to a combination of aspirin, Plavix, and Pletal for treatment of his severe peripheral vascular disease. He underwent a left-sided craniotomy and evacuation of subdural hematoma. Three days later, he had significant speech difficulty. There was a question of transient right-sided weakness. There was no witnessed convulsive activity. The assessment was aphasia related to seizure, stroke, or post-surgical "relaxation" of the brain causing transient symptoms. He underwent a second craniotomy. He did not recover well and was determined to have suffered a stroke. In May 2007, after surgery, he reported no cardiovascular complaints. His left hand weakness had improved. In June 2007, he reported problems with poor memory and headaches, but was otherwise well. He had experienced chest pain relieved with sublingual nitroglycerins. On June 2008 VA examination, the examiner noted that following the second craniotomy, the Veteran suffered three grand mal seizures which had since been controlled with anti-convulsive medications. After physically examining the Veteran, the examiner determined that the Veteran's seizure disorder was not caused by or related to his heart condition. The examiner stated that the vast majority of subdural hematomas were due to trauma in middle-aged males. Due to the bilateral nature of the Veteran's hematomas, in conjunction with the left temporal contusion, the examiner concluded that his stroke, with residual seizure disorder and speech dysfunction, was likely of traumatic etiology. The Veteran is currently in receipt of service connection for loss of use of both lower extremities status post popliteal aneurysm resection, coronary artery disease with hypertension, right peroneal nerve paralysis associated with a lumbar spine disability, peripheral neuropathy of the left leg, and rheumatoid disease of the bilateral shoulders, elbows, wrists, and fingers. However, at this time, the Veteran is not in receipt of service connection for peripheral vascular disease of the lower extremities. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2010). In this case, although the June 2008 VA examiner concluded that the Veteran's seizure disorder was not related to his coronary artery disease, no explanation was provided. Because the Veteran suffered from two strokes within two months after undergoing heart surgery, an explanation as to the relationship between the two disorders is necessary in this instance, in light of the Veteran's contentions. Further, although the examiner determined the Veteran's hematomas to be related to trauma, it is unclear on what basis such as conclusion was made, as no head injury was reported on hospitalization. Finally, a VA examiner should opine as to whether the Veteran's stroke and seizures were caused or aggravated by his anti-coagulant medication, and, if so, whether that medication was prescribed for the control of a service-connected disability, or for control of the peripheral vascular disease stemming from his service-connected aneurysm repair. Accordingly, the etiology of the Veteran's stroke and seizures remains unclear to the Board, a VA examination is necessary for clarification and to fairly decide the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to ascertain the etiology of his April 2007 stroke and seizures. The claims file must be reviewed by the examiner and the examination report should note that review. The examiner should provide the rationale for all opinions provided. The examiner should specifically opine as to whether it is as least as likely as not (50 percent probability or greater) that the Veteran's April 2007 subdural hematomas and grand mal seizures, and related residuals, were caused or aggravated by any service-connected disability, to include (1) coronary artery disease and hypertension status post coronary artery bypass graft in February 2007, or (2) anti-coagulation medication taken to control peripheral vascular disease status post popliteal aneurysm resections and status post abdominal aortic aneurysm. In that regard, the examiner should also opine as to whether it is as least as likely as not (50 percent probability or greater) that the Veteran's peripheral vascular disease was caused or aggravated by, or was otherwise related to, his popliteal aneurysm resections and abdominal aortic aneurysm resection. In rendering the requested opinions, the examiner should take into account the absence of any reported trauma to the head preceding the hematomas. 2. Then, readjudicate the claim. If the decision remains adverse to the Veteran, issue a supplemental statement of the case. Allow the appropriate time for response, then return the case to the Board. 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). _________________________________________________ Harvey P. Roberts 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) (2010).