Citation Nr: 1322032 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 04-28 499A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for normal pressure hydrocephalus. 2. Entitlement to service connection for petit mal seizures. 3. Entitlement to service connection for organic brain syndrome. 4. Entitlement to service connection for dementia. REPRESENTATION Appellant represented by: Dennis L. Peterson, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran had active service from July 1966 to July 1969 and subsequent service, including on active duty for training and inactive duty training, in the Naval Reserve. The Veteran reported that his Reserve duty included firefighting on one occasion in 1979. These claims came before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. This matter was remanded in August 2005, March 2006, and June 2009. In November 2005, the Veteran testified in support of his claims at a videoconference hearing held before the Board. In January 2011, the Board denied the Veteran's claims. This decision was appealed to the Court of Appeals for Veterans Claims (Court). In a memorandum decision dated in March 2012, the Court vacated the Board's decision and remanded the matter to the Board for further proceedings consistent with the Court's decision. The Veteran was informed by letter dated in June 2012 that the Veterans Law Judge who conducted the November 2005 hearing is no longer employed at the Board. The Veteran was offered the opportunity to have a hearing before another VLJ. In a response received in July 2012, the Veteran indicated that he did not wish to appear at another hearing. Thus, the Board will proceed with the adjudication of his claim. FINDINGS OF FACT 1. The Veteran's Chiari malformation is a congenital defect. 2. The Veteran did not experience a superimposed disease or injury during service that resulted in an additional disability or aggravation of his congenital Chiari malformation. 3. The Veteran's normal pressure hydrocephalus is not a result of service. 4. The Veteran's current petit mal seizures are not related to his active service, nor are petit mal seizures otherwise related to such service, or to a service-connected disability. 5. The Veteran's current organic brain syndrome is not related to his active service, nor is organic brain syndrome otherwise related to such service, or to a service-connected disability. 6. The Veteran's current dementia is not related to his active service, nor is dementia otherwise related to such service, or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for normal pressure hydrocephalus have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection for petit mal seizures have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. The criteria for service connection for organic brain syndrome have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 4. The criteria for service connection for dementia have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). VCAA Notice and Assistance Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. The notification obligation in this case was accomplished by way of a letter from the RO to the Veteran dated in August 2003 with regard to the seizure, organic brain syndrome, and dementia issues, and in January 2005 with regard to the hydrocephalus issue. While these notices do not provide any information concerning the evaluation or the effective date that could be assigned should service connection be granted, Dingess v. Nicholson, 19 Vet. App. 473 (2006), since this decision affirms the RO's denial of service connection, the Veteran is not prejudiced by the failure to provide him that further information. Although the notice provided to the Veteran in January 2005 was not given prior to the first AOJ adjudication of the claim, the notice was provided prior to initial certification of the Veteran's claim to the Board. Additionally, this matter was remanded in August 2005, March 2006, and June 2009, and the claimant has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notices. Therefore, to decide the appeal would not be prejudicial to the claimant. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any private/VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. Records of award of disability benefits from the Social Security Administration have been obtained. 38 C.F.R. § 3.159 (c) (2). A VA examination was conducted in July 2008, and the Board obtained a VHA expert medical opinion in February 2013. The VHA medical opinion contains sufficient factual detail and medical analysis such that the Board can rely on the medical opinion to make a fully informed decision on the claims. When VA undertakes to obtain a medical opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the medical opinion to the extent relied on is adequate as the opinion is predicated on a review of the Veteran's history and the opinion expressed is by a medical expert who has applied analysis to the significant facts of the case in order to reach the conclusions. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (an examination is adequate when it is based on consideration of the prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one); see also Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 304 (2008) (the guiding factors to be used by the Board in evaluating the probative value of medical opinion are the opinion is based upon sufficient facts or data, the opinion is the product of reliable principles and methods, and the expert has applied the principles and methods reliably to the facts of the case.). For these reasons, the VHA medical opinion is adequate. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Facts and Analysis The Veteran asserts that, during Reserve training in San Diego from August 10, 1979, to August 12, 1979, he suffered intense exposure to carbon monoxide while participating in fire fighting school. He explains that the exposure occurred because he was the designated leader and as such was not issued a breathing apparatus. The Veteran stated that each repetition of the exercise involved a 2-man hose team, plus the Veteran and one instructor, and lasted about 30 minutes. During the training exercise, the Veteran acted as the one who initially discovered the fire, and as a result, he was not wearing an Oxygen Breathing Apparatus. The Veteran alleges that exposure to carbon monoxide caused normal pressure hydrocephalus, which subsequently caused petit mal seizures, dementia, and organic brain syndrome. A service Report of Medical Examination dated in June 1969 for separation shows that the neurological evaluation was normal. In an annual Report of Medical Examination in March 1982, the neurological evaluation was normal. There are no other service treatment records related to normal pressure hydrocephalus, petit mal seizures, organic brain syndrome, or dementia. In December 1989, a MRI showed marked hydrocephalus with compression of the cerebral hemispheres with an apparent dilation of the lateral and third ventricles consistent with obstructive-type hydrocephalus and a Chiari malformation. In January 1990, private medical records show that the Veteran had two to four years of progressive deterioration of mental status and progressive ataxia. History included a two-year history of progressive difficulties since an accident in which he lost consciousness, and that since that time he had had a gradual deterioration of function including mild dementia, impaired memory, significant ataxia, unsteadiness of gait, and more recently some incontinence. In January 1990, he was treated with a right ventricular peritoneal shunt. In January 1993, the Veteran presented with the new onset of seizures since 1992. An assessment of mild residual organic brain syndrome was made in November 1993. In February 2002, the history of seizures was associated with hydrocephele. In October 2002, a VA physician stated that the organic brain syndrome was due to hydrocephalus. On VA examination in July 1994, the Veteran reported that he did well until 1989 when he was found to have hydrocephalus with Chiari malformation. The examiner noted that ten years previously the Veteran had developed a seizure disorder. The diagnoses were Chiari malformation with hydrocephalus and seizure disorder. VA records in September 1997 show that the Veteran was stable after hydrocephalus surgery. Private medical records from Dr. T.R.H. dated in June 2003 show that the Veteran underwent a right frontal temporoparietal craniotomy, evacuation of subdural hematoma, and placement of subdural and epidural drain, and was diagnosed with acute right frontal temporoparietal subdural hematoma. Private medical records from Dr. J.P. dated in August 2003 show that the Veteran fell from a ladder at work in June 2003, resulting in a subdural hemorrhage and traumatic brain injury. On VA examination in January 2004, the diagnosis was subdural hematoma, presumably acute, suffered in the summer of 2003. The VA examiner expressed the opinion that the Veteran's symptoms of normal pressure hydrocephalus had resolved. On VA examination in July 2008, the Veteran stated that he went to fire fighting school in the Reserve. He stated that while in fire fighting training there was one open wall and he became dizzy about six times during the training over eight hours, and again periodically over the next week. The dizziness was followed by vertigo during the second part of the first week. The Veteran gave a history of gait disturbance in 1983 and urinary incontinence before then. He stated that he had personality changes beginning in the early 1980s. The diagnosis was a history of alleged exposure to carbon monoxide in 1979 with an active Reserve training for firefighting noted on one occasion and the appearance of normal pressure hydrocephalus, which was dramatically relieved by a shunt in 1990; seizure disorder secondary to uncertain causes; and history of organic brain syndrome, not present. The VA examiner expressed the opinion that the diagnosed conditions were not related to carbon monoxide exposure in 1979. The VA examiner explained that carbon monoxide is a chemical and can insult the brain on a chemical basis. A chemical has not been shown to cause normal pressure hydrocephalus (NPH). NPH is a structural disease of a closure of the absorption pathways of fluid in and around the brain. The VA examiner found no evidence that carbon monoxide could cause or be implicated in the cause of NPH. The VA examiner could find no evidence of an association of carbon monoxide and the delayed onset of a seizure disorder, delayed onset of organic brain syndrome, or delayed onset of dementia. Private medical records from N.C.A., M.D., dated in March 2010 show that Dr. A. noted that the Veteran appeared to be quite stable with regards to normal pressure hydrocephalus. Dr. A. was unable to clearly correlate his current findings with the Veteran's medical history as a fire fighter in San Diego. In a May 2012 statement, Dr. A. stated the Veteran had underlying hydrocephalus with ventriculomegaly prior to his firefighter training, often referred to as compensated hydrocephalus. Dr. A. stated that patients with compensated hydrocephalus may become symptomatic after traumatic brain injuries or anoxic events, as any event of this nature may be enough to necessitate a ventricular shunting. Dr. A. further stated that he was unable to state with a reasonable degree of medical certainty that carbon monoxide exposure was the de facto cause of the Veteran's ventriculomegaly and ultimate shunt replacement, but that it was his opinion that it was as likely as not that the carbon monoxide exposure to which the Veteran was subjected while in the military service in 1979 did cause or substantially contribute to his hydrocephalus and subsequent shunting. Dr. A. explained that an anoxic event could deprive the brain of oxygen, which likely occurred in the situation described by the Veteran, when the Veteran was subjected to "high" levels of carbon monoxide without an oxygen mask. In February 2013, the Board obtained a VHA medical opinion from the Chief of Neurology of the Washington, D.C., VAMC. The VHA expert, a physician, stated that the Veteran likely had obstructive hydrocephalus based on the December 1989 MRI findings and the January 1990 medical record showing deterioration of his condition and symptoms of headache, ataxia, mild-moderate dementia, and difficulty controlling urine. He stated that the Veteran's Chiari malformation was a developmental disorder that was present at birth and typically becomes symptomatic in adolescence or young adulthood with trauma often the precipitating event. He noted that the Veteran had suffered a head injury severe enough to result in unconsciousness before the symptoms of hydrocephalus began. The VHA expert stated that it was is more likely than not that the injury explained the timing of the deterioration in his condition caused by hydrocephalus. Prior to the development of symptoms of hydrocephalus, the Veteran had a physical examination in the service that was normal." The VHA expert stated that it was possible, but not likely, that epilepsy was the result of the Chiari malformation. It was also possible, but not likely, that epilepsy was post-traumatic, caused by the accident that caused unconsciousness. In retrospect, the VHA expert noted that the Veteran had claimed non-specific symptoms that have been attributed to epilepsy, which predated this accident but the history was after the fact and it was possible either that the non-specific symptoms were not symptoms of epilepsy or that the symptoms started after the accident, and that it was more likely than not that the Veteran had epilepsy of a cause that was not obvious. The VHA expert further stated that: Carbon monoxide poisoning is not a recognized cause of obstructive hydrocephalus. It is therefore more likely than not that carbon monoxide poisoning did not cause obstructive hydrocephalus here. Carbon monoxide poisoning can cause hydrocephalus ex vacuuo. This means that there is such damage to the brain that so many brain cells died that the brain has become atrophic and the ventricles expand in size and just to fill the space formerly taken by the normal brain cells. Such patients are unlikely to gradually worsen from one single exposure to carbon monoxide. To be clinically meaningful a single exposure to carbon monoxide must overwhelm the patient, cause unconsciousness, cause him to develop seizures at the time of exposure. Typically, such patients are rushed to a hospital where they need CPR and oxygen to live. It is much more unlikely than not that gradual deterioration could result from a single carbon monoxide exposure in 1979 that started causing symptoms in 1986. It is similarly unlikely that such symptoms could be reversed, even temporarily, by a ventriculo-peritoneal shunt. It is finally, unlikely that carbon monoxide caused brain damage and the patient's symptoms rather than the Chiari malformation. He has the Chiari malformation. The connection between a single episode of carbon monoxide poisoning and obstructive hydrocephalus, headache, ataxia, urine dyscontrol, and dementia is less likely than not to exist as a clinical entity. The symptoms, their progression, their relief are unlikely to follow carbon monoxide exposure. Did he have carbon monoxide exposure? It is more likely than not that he did not have such an exposure. No doubt an exposure can occur in this manner but the history speaks of an open wall in the staged room made to look like one on board ship. The complainant had no symptoms of carbon monoxide at the time (1979). It is more likely than not that nothing this veteran developed almost a decade later had anything to do with his 1979 incident. He had no evidence of an acute neurological syndrome at the time of exposure or immediately afterward. It is more likely than not that he had no exposure to toxic levels of carbon monoxide and never developed any neurological symptoms from this one incident and that none of his many neurological symptoms a decade and more later were in any way related to carbon monoxide toxicity in 1979. In a May 2013 statement, B.N., M.D., who identified himself as a partner of N.C.A., M.D., stated that he had recently taken over the care of the Veteran. Dr. N. stated that the Veteran had reported to him that he suffered a brain injury from a 1979 event while leading a firefighting exercise, and was not given an oxygen breathing apparatus "for approximately thirty minutes in duration. This exposed him to high levels of carbon monoxide. He states that for several weeks after that event he suffered nausea, headaches, balance trouble. He reports that his cognitive decline and seizures as well as his walking difficulties began after this event." Dr. N. stated that from his review of CT scans of the Veteran performed from 2005 to 2011 there was no appearance of a Chiari malformation. He believed that the Veteran had a congenital condition called arrested hydrocephalus that was commonly associated with a developmental abnormality but was not a Chiari malformation. "In any case [the Veteran] had this condition at birth. The question at hand is if the fire fighting incident in 1979 in which he received likely a high dose of carbon monoxide resulted in him developing normal pressure hydrocephalus. Dr. N. continued: Normal pressure hydrocephalus appears to be a separate condition from any type of congenital hydrocephalus or even Chiari malformations. Normal pressure hydrocephalus is typically a disease associated later in life with a triad of: cognitive changes (especially with memory), gait disturbances, and urinary incontinence. It is [the Veteran]'s contention that these symptoms developed after the firefighting incident and they have improved with ventriculo-peritoneal shunting. Chronologically this certainly appears to be the case. I am not aware of any information regarding carbon monoxide poisoning causing normal pressure hydrocephalus. On the other hand the causes for normal pressure hydrocephalus are poorly understood. It would be unusual for [the Veteran] to develop normal pressure hydrocephalus at such a young age. Therefore, it is reasonable to conclude that carbon monoxide exposure is related to [the Veteran]'s development of normal pressure hydrocephalus. In a written statement dated in May 2013, the Veteran identified what he described as "erroneous statements" in the February 2013 VHA physician's report. Specifically, the Veteran stated that the VHA physician's reference to an "open wall staged area" was incorrect and the area was in fact enclosed; that he was subjected to multiple exposures to carbon monoxide during the course of the day-long training exercise (approximately 10 exposures of 30 minutes each over an eight to 10 hour period) rather than a "single exposure"; that he actually had neurological symptoms for a week or more after the 1979 incident, including headaches and dizziness. Normal Pressure Hydrocephalus Although the Veteran's Chiari malformation is a congenital defect and was present since his birth, it was not noted upon his entry into service. However, congenital or developmental defects automatically rebut the presumption of soundness and are therefore considered to have preexisted service. 38 C.F.R. §§ 3.303(c), 4.9. Service connection is generally precluded by regulation for such "defects", because they are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). Service connection is only possible for a congenital defect if there is evidence of additional disability due to aggravation during service of the congenital defect by superimposed disease or injury. See VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514- 15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. Thus, service connection is still possible for the Veteran's Chiari malformation if the evidence establishes he incurred additional disability during active duty service due to a superimposed disease or injury. The Veteran contends in part that his Chiari malformation was aggravated during service due to exposure to carbon monoxide in the fire-fighting training exercise, and that he suffered a superimposed or additional disability in the form of normal pressure hydrocephalus. As will be explained below, the evidence does not establish an additional disability due to a superimposed injury during service. The Veteran submitted articles from the Internet related to the diagnosis and treatment for normal pressure hydrocephalus, as well as the effects of exposure to carbon monoxide. A medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). The medical articles submitted by the Veteran in this case have been considered by the Board along with the medical opinions of record, however in and of themselves they do not provide sufficient evidence to establish a nexus between the Veteran's normal pressure hydrocephalus and an inservice cause. The Board has an obligation to weigh the probative value of the medical opinions presented based upon factors such as personal examination of the patient, knowledge and skill in analyzing the data, the knowledge and expertise of the examiner, the expressed rationale forming the basis of the opinion, ambivalence or exactness of diagnosis. The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The VA examiner in July 2008 expressed the opinion that the Veteran's normal pressure hydrocephalus was not related to his alleged exposure to carbon monoxide in 1979. The examiner, after considering the Veteran's report of dizziness and vertigo following the firefighting training, found no evidence for association of carbon monoxide exposure with the development of normal pressure hydrocephalus, or with the delayed onset of seizure disorder, organic brain syndrome, or dementia. The record contains two relevant statements from Dr. A. In the March 2010 statement, Dr. A. was unable to clearly correlate his current findings with the Veteran's medical history as a firefighter. In a subsequent May 2012 statement, Dr. A. stated that he was unable to state with a reasonable degree of medical certainty that carbon monoxide exposure was the de facto cause of the Veteran's ventriculomegaly and ultimate shunt replacement, but that it was his opinion that it was as likely as not that the carbon monoxide exposure to which the Veteran was subjected while in the military service in 1979 did cause or substantially contribute to his hydrocephalus and subsequent shunting. Dr. A. explained that an anoxic event could deprive the brain of oxygen, which likely occurred in the situation described by the Veteran, when the Veteran was subjected to "high" levels of carbon monoxide without an oxygen mask. The Board finds the statements of Dr. A. of limited probative value because the underlying assumption is that the Veteran was subjected to "high" levels of carbon monoxide, which has not been established. With respect to the May 2013 statement from Dr. N., the physician stated that he was unaware of any information regarding carbon monoxide poisoning causing normal pressure hydrocephalus, but the cause of normal pressure hydrocephalus was poorly understood. The physician stated that would be unusual for the Veteran to develop normal pressure hydrocephalus at such a young age. Therefore, it was reasonable to conclude that carbon monoxide exposure was related to the Veteran's development of normal pressure hydrocephalus. The Board finds the statements inconsistent. Dr. N. provides no basis for the conclusion that carbon monoxide exposure is related to development of normal pressure hydrocephalus and this does not logically follow from his previous statement that he is unaware of any information regarding carbon monoxide poisoning causing normal pressure hydrocephalus. As for the opinion of the VHA expert, the Chief of Neurology at VA medical center, the Board finds the opinion persuasive evidence that opposes the claim. The VHA expert provided a detailed rationale for the conclusions that hydrocephalus was likely triggered by a head injury years after the claimed exposure to carbon monoxide and that hydrocephalus was not consistent with exposure to carbon monoxide. The Board is aware that the Veteran has disputed the VHA physician's statements as to whether there was an open wall in the firefighting exercise and his characterization of a "single exposure" to carbon monoxide. The Board notes that the Veteran himself provided the history regarding the open wall at the VA examination in July 2008, and the current denial of that detail raises is inconsistent and the Board finds the Veteran not credibile as to the extent of any actual carbon monoxide exposure. The VHA expert expressed the opinion that the Veteran did not suffered from carbon monoxide exposure and he did not have neurological complaints at the time. The Veteran has disputed this and he states that he did suffer from headaches and dizziness shortly after the 1979 incident. However, even assuming this characterization by the VHA physician was incorrect, his opinion still provides strong evidence against the Veteran's claim. The VHA expert specifically stated that carbon monoxide exposure was not a recognized cause of the Veteran's type of hydrocephalus and the type of hydrocephalus that could be related to such exposure would require immediate unconsciousness, seizures at the time of exposure, and hospitalization necessary to save his life. As the Veteran has not at any time alleged such a severe immediate reaction to his alleged exposure, the VHA physician's opinion stands as persuasive evidence against his claim. The VHA Chief of Neurology's opinion is significantly more persuasive than the private medical opinions. It is based on an in-depth review of the cumulative evidence of record, is thorough, is supported by cogent rationale, and is consistent with other evidence of record, including the earlier March 1982 medical examination showing normal neurological examination and the July 2008 VA examination findings. Nieve-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran is competent to report symptoms and his firefighting training, but as lay person the Veteran is not competent to offer an opinion on a matter clearly requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board finds that the determination of whether normal pressure hydrocephalus is related to carbon monoxide is not a matter the Veteran as a lay person is competent to offer an opinion on. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Therefore, this is not a case in which the Veteran's lay statements or opinion alone can serve to establish an association between the claimed disability and the event in service. Petit Mal Seizures, Organic Brain Syndrome, and Dementia The Veteran essentially has claimed entitlement to service connection for petit mal seizures, organic brain syndrome, and dementia, as secondary to normal pressure hydrocephalus. Since service connection is not established for normal pressure hydrocephalus, there is not factual or legal predicate to support the claims of secondary service connection. And there is no persuasive evidence to support a finding that the current petit mal seizures, organic brain syndrome, and dementia are etiologically related to an injury, disease, or event in service. For these reasons, the preponderance of the evidence is against the claims of service connection for petit mal seizures, organic brain syndrome, and dementia, and the benefit of the doubt doctrine standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Service connection for normal pressure hydrocephalus is denied. Service connection for petit mal seizures is denied. Service connection for organic brain syndrome is denied. Service connection for dementia is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs