Citation Nr: 1326037 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 09-00 233A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a cerebral vascular accident (CVA), including as secondary to a service-connected varicose vein disability. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel INTRODUCTION The Veteran had active duty from August 1968 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the RO in Atlanta, Georgia. The Veteran appeared before the undersigned at a travel board hearing in February 2012. A transcript of the proceeding is of record. In June 2012, the Board sought a VHA opinion regarding the medical questions at issue. VHA opinions and addendum opinions were obtained in July 2012, November 2012, and January 2013. The Veteran has had an opportunity to respond to the opinions. In March 2013, the Veteran submitted additional evidence in response to the VHA opinions, with a waiver of review by the Agency of Original Jurisdiction (AOJ). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDING OF FACT The preponderance of the evidence shows that the Veteran's cerebral vascular accident cannot be attributed to active service or a service-connected disability. CONCLUSION OF LAW A cerebral vascular accident was not caused or aggravated by active service or a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, this information must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The AOJ informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claims in a letter dated in April 2007, wherein he was advised of the provisions relating to the VCAA. Specifically, he was informed of the evidence and information necessary to substantiate his service connection claims. Additionally, the Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to VA. The April 2007 letter also provided notice of the type of evidence necessary to establish a disability rating and effective date as was discussed in the Dingess case. Adjudication of the claims on appeal was undertaken in a February 2007 rating decision and a statement of the case (SOC) issued in December 2008. The Board acknowledges that the February 2007 rating decision was issued prior to the April 2007 VCAA letter however, the December 2008 SOC represents readjudication of the claim, thus curing any timing defect in the VCAA notice. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this regard, the RO associated the Veteran's private treatment records and VA outpatient treatment records with the claims file. Further, under 38 U.S.C.A. § 5103A (d), VA's duty to assist includes providing a claimant a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim and the claims file contains competent evidence that the claimant has a current disability and indicates that the disability may be associated with the claimant's service or service-connected disability. The types of evidence that indicate that a current disability may be associated with military service or service-connected disability include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In this case, the Veteran's claim was raised during a June 2006 VA examination for the underlying service-connected disability, varicose veins. The June 2006 examiner did not offer a nexus opinion with respect to the relationship between the Veteran's CVA and the service-connected disability. Subsequently, a May 2007 letter from the Veteran's registered nurse, J.W., indicated that there may be a relationship between the service-connected varicose veins, including vein-stripping treatment, and the CVA. The Veteran was not provided with a VA examination; however, as the need for a VA medical opinion was triggered, the Board sought a VHA medical opinion. As discussed in the introduction, a VHA opinion and addendum opinions were rendered in July 2012, November 2012, and January 2013. The Board acknowledges that the Veteran has challenged the adequacy of the VHA addendum opinion rendered by Dr. J.B. However, the Board has reviewed the opinion and finds that it is adequate. Specifically, the Veteran argues that the VHA opinion is inadequate because Dr. J.B. relied in part on 30-year old research in reaching his conclusion. While it is true that Dr. J.B. attached a medical journal article to support his conclusion and the article was written over 30 years ago, a notation on the article indicates that it was current and listed on a medical school website as recently as 2009. Additionally, more recent journal articles also attached in support of Dr. J.B.'s opinion do not contradict the article written in 1982. Additionally, the Board acknowledges that the Veteran submitted additional evidence since the most recent VHA addendum opinion but finds that another VHA addendum opinion to address the additional evidence would only unduly delay resolution of the claim. Specifically, the discussion presented in the medical journal article submitted by the Veteran, concerning shunts and travel of an embolism, was addressed by the VHA physician. Additionally, as explained below, the opinion submitted by Dr. I.P. regarding aggravation of "any current right leg disability" is speculative as the evidence of record does not demonstrate that the Veteran has a right leg disability other than that for which the Veteran is already service-connected. Thus, an addendum opinion is not required. Next, the Veteran was afforded a hearing before the Board in February 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ specifically noted the issue as entitlement to service connection for CVA secondary to his service-connected varicose vein disability. Transcript [T.] page 2. The Veteran was assisted at the hearing by an accredited representative from Georgia Department of Veterans Service. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of this claim. In addition, the VLJ asked the Veteran if anyone had ever related the CVA to his varicose vein disability. T. page 5, 12. The VLJ also sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. T. pages 14-15. The Veteran also acknowledged that he would need to show that he had a link between the CVA and his service-connected disability and discussed a letter written by his physician in support of his claim. T. page 5. The VLJ also asked the Veteran pertinent questions regarding his service in order to ascertain whether he might be entitled to service connection under a different theory of entitlement, including on a direct basis. T. page 12. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claim for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence that related the Veteran's CVA to his varicose vein disability, the only element of the claim in question. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2). In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. II. Service Connection In the present case, the Veteran claims that he had a CVA in 2000 that occurred as a result of his service-connected varicose vein disability, and that he has current residuals of the CVA. For the reasons explained below, the claim fails for lack of a relationship between the CVA, and/or its residuals, and the service-connected disability. Service connection is warranted for a disability, which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Board notes that 38 C.F.R. § 3.310 was amended effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. The revised regulation requires comparison of the baseline level of severity of the disorder in the absence of the service-connected disability to the increased severity, and provides compensation only if there is an increase in severity. 38 C.F.R. § 3.310 (2012). As the Veteran's claim was initiated in June 2006, prior to the revision, the more stringent standard does not apply. In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. As background, the Veteran's service treatment records (STR) show that he was not treated for varicose veins of the right lower extremity or for a CVA or residuals of a CVA at any time in service. The records show that the Veteran incurred a gunshot wound to the lower right thigh in September 1969 while in Vietnam. X-rays taken in September 1969 show shell fragments in the soft tissues of the right thigh. Service connection has been established for varicose veins of the right lower extremity, residuals of a shrapnel wound to the right posterior thigh, tender scars of the right posterior thigh and residuals of a shrapnel wound and vein stripping, and for residuals of a fragment wound to the right common peroneal nerve. Post-service evidence shows that the Veteran had vein stripping in the right lower extremity in August 1997, to treat his varicose veins. In October 1999, Dr. W.W.R. stated that the Veteran had evidence of venous valvular reflux disease, and this was the likely etiology of his recurrent varicosities. A private brain computerized tomography (CT) scan taken in April 2000 showed a small lacunar infarction in the left basal ganglia "which is probably old" and a suspected small focus of infarction in the left periventricular white matter "which is of uncertain age." Later in April 2000, it was noted that the Veteran had been hospitalized recently for left hemispheric CVA and "is now able to walk without his cane. His strength overall has improved." Physical examination showed a slight right facial droop, improved speech, and a regular heart rate and rhythm without murmur, rub, or gallop. The impressions included status-post left hemispheric CVA, "neurologically improving." A private carotid Doppler of the bilateral lower extremities taken in April 2000 was normal and showed no evidence of deep vein thrombosis. A private echocardiogram (EKG) was taken in April 2000 to "[r]ule out cardiac source of emboli in a patient with cerebrovascular accident." The EKG was normal with no cardiac source of embolus. In May 2000, a private neurological examination was unremarkable except for a slight decrease in grip strength on the right compared to the left, clear speech, and the Veteran was "ambulating well without a cane." The impressions included status-post left hemispheric CVA, neurologically improving, of unclear etiology. A private transesophageal EKG taken in May 2000 essentially was normal "with no cardiac source of embolus seen" and no evidence of interatrial shunting. In June 2000, it was noted that the Veteran had stopped physical therapy "because he has completely regained strength on the right side." He also had been cleared to drive and fly "but [the Veteran] had a negative transesophageal echocardiogram and thus the etiology of his CVA is unclear." No gross motor focal deficits were noted on neurological examination. Speech was clear. The impression was status-post CVA, etiology unclear, with no further neurological deficits. In April 2001, it was noted that the Veteran had a right leg venous lake present which was "fairly large in nature." Compression at this site was recommended. The Veteran also was advised that surgical excision could be performed but he did not want to do that. There was no evidence of thrombosis, significant tenderness, or phlebitis. The plan was for the Veteran to use support hose, take 1 aspirin per day, and follow up as needed. In March 2004, the Veteran complained of pain in his legs. A history of varicose veins since the 1970's and segmental stripping was noted. The Veteran stated that he had been shot in the legs and then developed varicose veins. He was wearing a support sock. Objective examination showed a very large torturous vein along the right greater saphenous area which extended from the mid-inner thigh to the knee without ulcers or edema. An ultrasound of the right lower extremity showed no evidence of deep vein thrombosis, and significant reflux in the greater saphenous vein, common femoral vein, and posterior tibial vein. The assessment was varicose vein. VA carotid ultrasound taken in October 2005 showed no significant internal carotid artery stenosis bilaterally. In a June 2006 letter, J.W., R.N., submitted a statement in support of the Veteran's claim in which she stated that she had observed "a gradual increase in the frequency and duration of edema" in the Veteran's right thigh. His right thigh veins had become markedly distorted and "are constantly very firm, warm, and painful to touch." She also stated that the Veteran's edema "progressively does not reduce with elevation. Often it is still edematous in the morning after sleeping horizontally all night." She stated further that it was "very possible" that the Veteran's CVA was related to "the venous lake in his right popliteal area" at the time he experienced a CVA in March 2000. The Veteran had reported to J.W. that he had complained of acute pain, edema, and "pulsating spasms" in the right popliteal area for several days prior to his CVA. He also experienced right-sided weakness and paralysis, slurred speech, and confusion. J.W. opined: Given the fact that no other evidence could support the etiology, it is medically possible and certainly should be considered that the venous pooling could be the source of micro embolism and/or fragmentation leading to the CVA. Although this is not the usual, the possible must always be considered to be medically accurate. In a May 2006 letter, R. S. , M.D., stated that he had been providing the Veteran with dermatologic care "for several years." Dr. R.S. also stated that the Veteran "presently has severe varicose veins on the right inner thigh and leg-above and below the knee, related to the bullet wound" he incurred in the in-service gunshot wound. Dr. R.S. also stated that the Veteran experienced 2-3 cm swelling and marked distortion and edema of the thigh and leg. He finally stated that the Veteran "plans to have laser treatment of these vessels, after having had stripping performed several years ago." In a May 2007 letter, J. W. largely repeated her June 2006 clinical observations. She also stated, "Having experienced a vein stripping in 1997 indeed placed [the Veteran] at risk for the CVA that he actually suffered in 2000." In a May 2007 statement, the Veteran contended that his CVA "was a secondary effect of the stripping of the varicose veins in the right leg by the VA in 1997 which was caused by the fragment wound to my right leg that was caused by direct enemy hostile fire in Vietnam." In a January 2009 letter, Dr. R.S. stated that the Veteran's varicose veins on the right thigh and leg "represent a significant quantity of blood pooling." A history of venous stripping procedures was noted. Dr. R.S. also stated that there was a "possibility of cerebral microemboli with further possibility of cerebral infarction." In a January 2012 letter, J. W. stated that the documentation in the claims file indicates significant pooling of blood in the Veteran's right leg where the vein stripping had occurred during the hours leading up to the CVA. At any time, this pooling places the Veteran at risk for the formation of clots due to stasis of circulating blood and consequently, a myocardial infarction, pulmonary embolism, or another CVA. J.W. noted medical treatise evidence which, according to J.W., supported the potential for microembolism to travel from pooling of blood in the lower extremities, resulting in a CVA. Following a review of the evidence in this case, the Board finds that the Wallin elements (1) and (2) have been met as the Veteran had a CVA described as a small lacunar infarction in the left basal ganglia in 2000, currently has residuals of slurred speech and right-sided weakness, and is service-connected for varicose veins. However, the claim fails as element (3), a relationship between the service-connected disability and the current disorder(s), is not met. Here, the Veteran asserts that his CVA was caused by an embolism due to the service-connected varicose veins which led to pooling blood in his lower right extremity. In support of his claim, the Veteran offered several medical opinions and submitted medical information regarding the types of emboli: sources and possible pathologic consequences. An Expert Medical Opinion was ordered to address the complex medical question at issue. In VHA opinions dated in November 2012 and January 2013, Dr. J.B. explained that there are several different types of strokes. He found that the Veteran's stroke, a lacunar stroke, is not the type that would be caused by emboli (from pooling blood). He stated that there are two broadly defined groups of strokes; hemorrhage or bleeding, and blockage of blood flow, usually arterial blood flow. As applied to the Veteran's case, the examiner noted that hemorrhages can be caused by abnormal blood vessels (such as aneurysms or malformations) that have weak walls and hence tend to burst and cause bleeding, particularly in cases of trauma or from abnormalities in blood clotting factors. He stated that the Veteran did not have any major problem known due to bleeding into the brain, thus essentially ruling out a hemorrhage stroke. The examiner went on to discuss the blockage of blood flow and noted that this is the most common type of stroke. The blockage can be a narrowing event to the point of total blockage from things as diverse as air bubbles, white or red clots, debris from inter-arterial injections (traumatic or drug abuse) or in the case of trauma to the bones, particulate of fat that can block a vessel. He discussed the process called lipohyalinosis, a pathological term based upon characteristics of the abnormalities seen under a microscope in affected small caliber blood vessels. This process is associated with risk factors such as diabetes and high blood pressure, and blockages of small blood vessels will typically cause small strokes in the brain. Blockages are identified based upon their microscopic, clinical, and imaging characteristics. Lipohyalinosis causes a type of stroke called a lacune, which means a lake because it contains fluid and looks like a lake at post-mortem exam, and with CT and MRI scans. These are usually a centimeter or less in diameter, and are general much smaller than a stroke caused by a fresh blood clot that is sent down stream in an artery and blocks a major blood vessel. When a major blood vessel is blocked, the result is a large wedge-shaped stroke on imaging. It was noted that this type of stroke tended to be seen in the brain stem and in the deep parts of the brain, as opposed to the larger wedge-shaped more superficial larger types of stroke. . Dr. J.B. explained that even if there had been an emboli related to the varicose veins, it would have been trapped in the heart or lungs and not reached the Veteran's brain to cause the CVA. Dr. J.B. noted that the exception would be if there was a shunt in the Veteran's heart or lungs, then the embolism may reach the brain. However, Dr. J.B. reviewed the evidence from the time of the Veteran's stroke and noted that an echocardiogram was done after the stroke and did not show a shunt in the heart or lungs. Dr. J.B. also based his opinion, in part, on several medical texts, which as discussed in the VCAA section above, are found to be reliable despite one dated in 1982. The Board acknowledges that letters from the Veteran's registered nurse and another physician indicate a relationship between the Veteran's CVA and service-connected varicose veins. See J.W.'s letter dated in May 2007 and Dr. R.S.'s letter dated in January 2009. Dr. R.S. opined that the Veteran's varicose veins on the right thigh and leg represented a significant quantity of blood pooling and that with the pooling and the vein-stripping procedure, "there may be a possibility of cerebral microemboli with further possibility of cerebral infarction." The Veteran's registered nurse, J.W., opined that the Veteran's signs and symptoms (including pain, edema, pulsating spasm, chest pain, shortness of breath, and right-sided weakness) displayed in the few days leading up to the CVA indicate a very possible relationship to the venous lake in his right popliteal area at the time. She also cited the subsequent echocardiogram results as well as a bilateral carotid Doppler examination, which were both normal, and a follow-up medical examination in which the physician noted that the etiology of the CVA was still undetermined. She concluded that the 1997 vein stripping combined with the negative test results indicated an etiology directly related to the Veteran's primary war-related injury (which resulted in varicose veins). She went on to opine that given the fact that no other evidence could support the etiology, it is medically possible and should be considered that the venous pooling could be the source of microembolism leading to the CVA. She cited a medical textbook that contained a statement that pathological consequences of venous emboli may occlude a cerebral vessel. In a January 2012 letter, J.W. also opined that it is "more likely than not" that the Veteran's stroke was caused by his varicose veins. She emphasized that the Doppler ultrasound to rule out deep vein thrombosis is known to be less than 100 percent accurate and that a further study, such as a venography would have been justified but did not occur in the Veteran's case. J.W. reasoned that the Veteran did not have any other causative issue leading up to the CVA, except for the service-connected venous insufficiency. The Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board has reviewed all of the medical opinions of record and finds that the VHA neurologist's, Dr. J.B., opinion outweighs the opinions of J.W. and Dr. R.S. First, Dr. R.S.'s opinion was speculative. He noted that he had provided the Veteran with dermatologic care for years. There is no indication that this doctor has the neurological expertise to answer the question of stroke origin in this case. He merely noted that "there may be a possibility of cerebral microemboli with further possibility of cerebral infarction." (Emphasis added). Medical opinions which are speculative, general or inconclusive in nature cannot support a claim. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) [ Additionally, Dr. J.B.'s opinion outweighs J.W.'s opinion because Dr. J.B. is a neurologist with more training and experience in the field of etiology of a stroke than J.W., who is a registered nurse and holds a master's degree. Further, the Board finds Dr. J.B.'s analysis is more probative than J.W.'s analysis because Dr. J.B. discussed causation of the two different types of strokes and distinguished between the type of stroke that the Veteran had verses strokes caused by hemorrhaging and thrombosi. Neither J.W., nor Dr. R.S., discussed the fact that there are multiple types of stroke nor did they identify the type of stroke the veteran experienced. Moreover, J.W.'s opinion did not address the fact that the lacunar stroke is not commonly caused by emboli. The Board appreciates J.W.'s explanation that the Veteran may well have had an emboli despite the fact that the Doppler ultrasound did not show a venous lake and that there was a lack of additional studies after the CVA. However, this does not address Dr. J.B.'s opinion that even if the Veteran had an emboli, it would have been trapped in the heart or lung and not reached his brain without a shunt, which was not found on other testing. Significantly, Dr. J.B. considered that there is a slight chance that the Veteran's type of stroke could be caused by emboli, and still opined that it was less likely than not caused by emboli. Dr. J.B. based his opinion on the testing that was done following the CVA. The Board acknowledges that the Veteran reported that the echocardiogram referenced by Dr. J.B. only addressed whether there was a shunt in heart but the Board finds Dr. J.B.'s interpretation of the echocardiogram to be more probative as Dr. J.B. is an experienced neurologist. The Board has also considered the medical journal article submitted by the Veteran, "Cerebral Microemboli during Hip Fracture Fixation: A Prospective Study." The article discusses the possibility of a microembolism traveling from the leg to the brain by way of a shunt, as discussed above. Additionally, the article indicated that the appropriate test to determine whether a shunt was present was to provide the patient with an echocardiogram. As discussed above, the VHA physician, Dr. J.B. addressed the possibility that the Veteran could have had an embolism that traveled but that an echocardiogram at the time of the stroke indicated that the Veteran did not have a shunt in the heart or lungs. The Board has also considered the Veteran's statements that he had a partially collapsed lung prior to the CVA and that might have had something to do with an emboli traveling to his brain. T. page 9. See also November 1999 private treatment record demonstrating a slightly underinflated lung. The Board has also considered the Veteran's reports of feeling as if something was moving up his right leg during the month prior to the CVA. T. page 7. He also tasted blood during the month prior to the CVA. T. page 8. He is competent to report his personal observation as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to interpret that observation and diagnosis an emboli traveling through his body and/or causing a CVA. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of a CVA, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Significantly, the evidence does not indicate that an underinflated lung would cause emboli travel to brain. The Board has also requested a medical opinion to consider the question of whether any current residuals of the Veteran's CVA may be aggravated by the Veteran's service-connected varicose vein disability. As discussed above, the Veteran reported to his registered nurse, J.W., that he has residuals including slurred speech and right-sided weakness. The Board acknowledges that a March 2013 opinion by Dr. I.P. that it is at least as likely as not that the Veteran's service connected varicose veins of the right lower extremity aggravated his current residual of a CVA. Dr. I.P. did not specifically identify any particular residual that the Veteran claims to have (i.e., slurred speech and/or right-sided weakness). Further, his rationale pointed to a right leg disability but failed to actually identify any current right leg disability. Specifically, Dr. I.P.'s rationale was that "[t]hese manifestations of venous disease can produce significant leg disability and this leg disability can aggravate any right leg disability that has resulted from the [V]eteran's CVA." Dr. I.P. did not confirm that there actually was a residual right leg disability from the CVA. Indeed, the evidence of record does not indicate that the Veteran has a right leg disability or that he has claimed such, other than the varicose vein disability for which he is already service-connected. Based on the foregoing, the Board finds Dr. I.P.'s opinion to be speculative. Thus, the opinion does not support a finding that the Veteran's CVA, and residuals of slurred speech and right-sided weakness, were caused or aggravated by the service-connected varicose vein disability. As the probative evidence of record does not indicate that the Veteran's CVA, or its residuals, were caused or aggravated by his varicose vein disability, Wallin element (3) has not been met. Thus, service connection must be denied on a secondary basis. Although the Veteran claimed secondary service connection, the Board has also considered whether he is entitled to service connection on a direct basis. Service connection may be granted, on a direct basis, if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and/or third Davidson elements, for specific chronic diseases only, is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances lay evidence of a nexus between the present disability and the post-service symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). The specific chronic diseases to which 38 C.F.R. § 3.303(b) applies, are listed at 38 C.F.R. § 3.309(a). See Walker, 708 F.3d at 1338. Brain hemorrhage and brain thrombosis are included in the list of specific chronic diseases to which 38 C.F.R. § 3.303(b) applies. In this case, however, the claim fails on a direct basis as well because there is no indication of an in-service incurrence of a CVA or symptom of a CVA, or a link between the Veteran's CVA and service or service injury. The Board acknowledges J.W.'s May 2007 letter cited above, in which she opined that the 1997 vein stripping combined with the negative test results indicated an etiology directly related to the Veteran's primary war-related injury. However, it is clear from the remainder of the letter that her opinion applied to a relationship between the CVA and the residuals of the service injury - the service-connected varicose veins. There is no indication that the Veteran's shrapnel wounds in service led to the Veteran's CVA some 30 years following service. The Veteran does not claim otherwise. For the foregoing reasons, service connection is not warranted for a CVA, on direct or secondary bases. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a cerebral vascular accident, including as secondary to a service-connected varicose vein disability, is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs