Citation Nr: 1751459 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 14-06 837 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for stroke with residual transient ischemic attacks (TIAs), to include as secondary to service-connected hypertension. ATTORNEY FOR THE BOARD T. Minot, Associate Counsel INTRODUCTION The Veteran served on active duty in the Air Force from November 2001 to October 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In March 2016, the Board remanded the claim for service connection for TIAs for evidentiary development, to include obtaining outstanding Social Security Administration medical records. The Board finds there has been substantial compliance with its March 2016 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board notes that a claim for service connection encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 5, 9 (2009). In light of Clemons and after reviewing the evidence of record (discussed in greater detail below), the Board has recharacterized the Veteran's claim for TIAs to one for stroke with residual TIAs, as reflected on the title page. Pursuant to a March 2016 Board decision, the RO effectuated the Board's grant of service connection for the Veteran's somatoform disorder and hypertension in an April 2016 rating decision, assigning initial ratings of 70 percent (somatoform disorder) and 0 percent (hypertension). The Veteran submitted a Notice of Disagreement (NOD) in May 2016 contesting the assigned ratings. Additionally, the Veteran's application for a total disability rating based upon individual unemployability (TDIU) was denied in a March 2017 rating decision, and the Veteran filed an NOD with that decision in April 2017. The RO is currently in the process of addressing these issues. FINDING OF FACT The Veteran's stroke with residual TIAs is causally related to his service-connected hypertension. CONCLUSION OF LAW The criteria for entitlement to service connection for stroke with residual TIAs have been met, on a secondary basis. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (2014); 38 C.F.R. § 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that he has suffered strokes and TIAs secondary to his service-connected hypertension. For the following reasons, the Board finds that entitlement to service connection is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (2014); 38 C.F.R. § 3.303(a) (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may also 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). Additionally, service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence of record may be summarized as follows. In June 2009, the Veteran sought emergency treatment for symptoms of left-sided facial droop, left-sided weakness, and elevated blood pressure with systolic pressure as high as 182 and diastolic pressure as high as 124. See St. Catherine Medical Center, Emergency Department Clinical Notes (June 2009). He was subsequently diagnosed with an acute ischemic infarction and cardiovascular embolism with aortic atherosclerosis. The record shows that he has been treated throughout the appeal period for multiple episodes of stroke-like symptoms, commonly diagnosed as TIAs. In October 2011, the Veteran underwent a VA neurologic examination. The examiner's impression was that the Veteran's recent history was "certainly consistent with having strokes with minor neurologic residuals and conceivably related to a prothrombin gene mutation," a hereditary problem. In September 2012, the Veteran underwent a VA examination of the central nervous system. The report noted that he had had a stroke in 2009 "due to a genetic condition, specifically a G20210A mutation"-i.e., prothrombin gene mutation. The examiner indicated that the Veteran had no cerebral vascular accidents (CVAs) in service but reiterated that there was a "high probability" that his genetic condition was the primary cause. No rationale was provided for this opinion. At the time of the examination, the Veteran exhibited "minor neurologic residuals" that the examiner noted were "conceivably" related to his prothrombin gene mutation. In August 2015, the Board referred the Veteran's claim to an independent medical specialist for an expert opinion regarding the etiology of his strokes and/or TIAs. In pertinent part, the medical expert noted in a September 2015 opinion that the Veteran's prothrombin gene mutation was a congenital or inherited condition which was static. Furthermore, the expert explained that the Veteran's history of strokes was secondary to arterial disease and was not in fact related to his genetic mutation. Indeed, a study demonstrated that his specific mutation was not shown to be associated with increased risk of stroke or myocardial infarction. Thereafter, the Veteran submitted correspondence clarifying that he believes his strokes were secondary to his service-connected hypertension. See Correspondence (received by VA in January 2017). Clinical notes from his private neurologist, dated in June 2016, reflect that given the Veteran's elevated blood pressure readings at the time of his June 2009 stroke, the stroke was "likely hypertension related." In November 2016, the Veteran underwent a VA Hypertension examination in which the examiner acknowledged that there was some evidence that the Veteran's strokes "were caused by hypertension." However, the VA examiner explained that "a record review shows he has a genetic mutation and a history of hyperhomocysteinemia, [both] of which contribute to hypercoagulopathy and early development of thrombolic/embolic events." In this case, the Board finds that the evidence of record warrants a grant of service connection on a secondary basis. In short, the evidence described above establishes that the Veteran had a stroke in June 2009 with several subsequent TIAs. Although initial VA examination reports suggests that the stroke was due to a genetic mutation, the September 2015 expert medical opinion clarified that there was no known association between such mutation and strokes. Thereafter, clinical notes from the Veteran's neurologist indicate that his June 2009 stroke was likely hypertension-related, as his blood pressure was extremely high prior to the stroke. The November 2016 VA Hypertension examination report opined otherwise; however, the basis for that opinion has been discredited by the September 2015 expert medical opinion, which found that the Veteran's gene mutation had no causal relationship with his strokes. In light of VA's policy of resolving reasonable doubt in the Veteran's favor, the Board finds that there is sufficient positive evidence of record to support an award of service connection. In sum, the weight of the evidence supports a finding that the Veteran had a stroke in June 2009 which was causally related to his service-connected hypertension. Service connection for stroke with residual TIAs, on a secondary basis, is therefore warranted. See 38 C.F.R. § 3.310. ORDER Entitlement to service connection for stroke with residual TIAs, as secondary to hypertension, is granted. ______________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs