Citation Nr: 1803068 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 14-11 050 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUE Entitlement to service connection for the residuals of an intracerebral hemorrhage (claimed as stroke), to include as secondary to insomnia associated with service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M. Bilstein, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1969 to August 1970 and was awarded the National Defense Service Medal and the Armed Forces Expeditionary Medal (Korea). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). VETERAN'S CONTENTIONS The Veteran asserts that service connection for the residuals of an intracerebral hemorrhage is warranted as a result of insomnia due to his service-connected PTSD. He reported that since his separation from service he has had impaired sleep, hypervigilance, and nightmares. He contends that his impaired sleep is attributed to his service-connected PTSD and medical studies indicate that insomnia can increase the risk of stroke up to 40 percent. See January 2014 Notice of Disagreement and April 2014 Substantive Appeal. FACTUAL FINDINGS 1. Service treatment records are absent complaints and treatment for an intracerebral hemorrhage or insomnia. 2. The Veteran is service connected for PTSD, effective August 8, 2012. A January 2013 VA PTSD examination report documents that the Veteran's PTSD resulted in impaired sleep, to include night sweats, and that this has been an ongoing problem since his separation from service. The examiner determined the Veteran had chronic sleep impairment attributed to PTSD. See January 2013 VA PTSD Examination Report and February 2013 Rating Decision. 3. At a July 2011 medical visit, the Veteran reported frequent nightmares, vigorous movement, and frequent awakenings throughout the night. He reported sleep issues for the past 15 to 20 years. His clinician determined the Veteran had a low Epworth Sleepiness score of 5 out of 24. See December 2012 Medical Treatment Record - Non Government Facility. 4. A July 2011 polysomnogram report reflects that the Veteran reported sleep interrupted by snoring, apnea, night sweats, hypervigilance, and nightmares. He also indicated he gets two to three hours of sleep per night but only has one caffeinated drink per day and a body mass index of 26. Although the clinician diagnosed the Veteran with mild sleep apnea, he determined that the Veteran did not require treatment for sleep apnea and recommends that he be referred to a mental health provider for treatment of PTSD and impaired sleep. See December 2012 Medical Treatment Record - Non Government Facility. 5. At an October 2012 psychological evaluation, the Veteran reported that his most distressing symptoms were being unable to sleep for longer than three hours per night since his separation from service, nightmares of being pursued and stabbed, and anxiety. He also indicated that he flails violently in his sleep. The private psychologist determined the Veteran's PTSD resulted in difficulty falling and staying asleep, feeling unrested after sleep, physically restless sleep, nightmares five to six nights per week, and PTSD flashbacks during sleep, among other symptoms. See December 2012 Medical Treatment Record - Non Government Facility. 6. Post-service treatment records reflect that the Veteran had an intracerebral hemorrhage in November 2012. In a February 2013 follow-up treatment note, the Veteran's neurologist determined that although there was no clear etiology for his stroke, chronic sleep deprivation in the context of PTSD might have played a causal role. The neurologist further explained that there is evidence of obstructive sleep apnea leading to decreased quality of sleep as a risk factor for vascular disease and stroke, and thus chronic sleep deprivation probably played a similar role. See March 2013 Medical Treatment Records - Non Government Facility and June 2013 Correspondence. 7. In a May 2013 addendum PTSD opinion, the January 2013 examiner opined that it is common for veterans with PTSD diagnoses to have sleep disturbance, as night sweats, hypervigilance, and nightmares common with PTSD are shown to impact quality of sleep. He further explained that hypervigilance impacts the quality of sleep in such a way that individuals with PTSD are easily awakened by small sounds and have difficulty accessing theta wave (deep) sleep. The examiner determined that it was at least as likely as not that the Veteran's chronic sleep problems are related his service-connected PTSD. See May 2013 C&P Exam for DBQ PTSD. 8. In a May 2013 Compensation and Pension Exam Report, the VA examiner noted that the Veteran had sleep disturbances, specifically insomnia, and noted a November 2012 diagnosis of intracerebral hemorrhagic stroke. She opined that based on medical literature, it is at least as likely as not that the Veteran's intracerebral hemorrhagic stroke is caused by or related to his chronic sleep impairment associated with his service-connected PTSD. The examiner referenced a March 2009 study that determined short- and long-sleep duration was associated with increased mortality from cardiovascular disease, non-cardiovascular diseases, and all causes for both sexes. See May 2013 C&P Exam. 9. In a January 2014 addendum opinion, a different VA clinician opined that there is no objective clinical evidence in medical literature to support a direct cause and effect concerning how the Veteran's service-connected PTSD would cause his mild sleep apnea and in turn cause his November 2012 intracerebral hemorrhagic stroke. She explained that the etiologies of an intracerebral hemmorhagic stroke do not include sleep apnea and therefore a clinical association would not be plausible. See January 2014 C&P Exam. 10. In January 2014, the Veteran's VA physician opined that the January 2014 VA addendum inappropriately focused on sleep apnea, which the Veteran did not contend was a cause of his stroke. The VA physician opined that the Veteran's PTSD night terrors and insomnia are associated with spikes in blood pressure and small artery damage in the brain, resulting in intracerebral hemorrhage. See February 2014 Medical Treatment Records - Government Facility. 11. In a February 2014 statement, the Veteran private neurologist explained that various forms of sleep irregularities increases one's risk of a stroke, likely due to disturbed sleep patterns and that new research clearly documents the effect of long-term insomnia in relation to an increased risk of stroke. As such, the neurologist opined that the Veteran's long-term, severe insomnia was a causative factor in his November 2012 cerebrovascular event. In support of his opinion, the neurologist submitted medical literature documenting the association between insomnia and the risk of cardiovascular events including stroke. See March 2014 Medical Treatment Records - Non Government Facility. 11. In a March 2014 VA addendum opinion, another VA clinician opined that the Veteran's PTSD did not cause or affect his stroke. The clinician stated that the medical references the Veteran provided most likely referenced an ischemic stroke, which is more common, and not the type of stroke the Veteran had-an intracerebral hemorrhagic stroke. He also indicated that Up-to-Date, an online medical resource provided by VAMC, did not mention psychological conditions, including those with sleep issues, to cause or potentially cause intracerebral hemorrhages. See March 2014 C&P Exam. 12. In June 2014, the Veteran submitted medical literature documenting that insomnia may raise the risk of a heart attacks, cardiovascular disorders, and strokes. See June 2014 Correspondence. 13. The Veteran's intracerebral hemorrhage is related to his insomnia associated with service-connected PTSD. LEGAL CONCLUSION The criteria for service connection for the residuals of an intracerebral hemorrhage are met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION At the outset, the Board notes procedurally that additional evidence has been associated with the claims file following the most recent statement of the case (SOC), and that the Veteran has not waived consideration of that evidence by the Agency of Original Jurisdiction (AOJ). However, that evidence was submitted by the Veteran and referral to the AOJ is not, therefore, required. In addressing why the Veteran's intracerebral hemorrhage is related to service, including insomnia associated with service-connected PTSD, the Board considers the May 2013 VA medical opinions, the February 2014 private neurologist opinion, and the January 2014 opinion by the Veteran's VA clinician to carry the greatest probative weight of the entirety of the evidence of record. The Board finds that these opinions, provided after reviewing the entirety of the claims file, when read together demonstrate a positive causal relationship between the Veteran's stroke and the insomnia associated with his service-connected PTSD. These opinions are highly probative as they reflect consideration of all relevant facts. The examiners and clinicians provided detailed rationales for the conclusion reached. Their conclusions are also supported by the medical evidence of record, which includes post-service treatment records documenting treatment for chronic sleep impairment associated with service-connected PTSD treatment, accepted medical literature supporting an increased risk of stroke associated with impaired sleep, and findings that the Veteran's PTSD night terrors and insomnia are associated with spikes in blood pressure and small artery damage in the brain resulting in intracerebral hemorrhagic stroke. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The Board acknowledges the January 2014 VA addendum opinion stating that the Veteran's PTSD did not cause sleep apnea and in turn did not cause an intracerebal hemorrhagic stroke. However, the Board finds that this opinion is inadequate as it did not address the question asked, whether the Veteran's intracerebral hemorrhage was caused by or related to his insomnia/chronic sleep impairment associated with service-connected PTSD. Instead, the clinician determined that medical literature did not support sleep apnea as a cause for intracerebral hemorrhage. The Board also acknowledges the March 2014 VA addendum opinion stating that there is no connection between the Veteran's PTSD and his intracerebral stroke, as medical literature did not mention psychological conditions as a cause or potential cause. However, the March 2014 clinician did not address the positive opinions of record reflecting that new research clearly documents the effect of long-term insomnia in relation to an increased risk of stroke and that PTSD symptoms of chronic sleep impairment are associated with spikes in blood pressure and small artery damage in the brain, resulting in intracerebral hemorrhage. The Board finds the January 2014 and March 2014 VA addendum opinions to be of minimal probative value and deficient because they are not supported by a well-reasoned rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) ("A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion.") When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Here, in light of the positive and negative evidence of record, to include specifically the Veteran's post-service treatment records and VA examination report, the Board finds that the evidence is at least in equipoise regarding whether his service-connected PTSD caused the Veteran's intracerebral hemorrhage. Hence, affording him the benefit of the doubt, service connection for an intracerebral hemorrhage is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for the residuals of an intracerebral hemorrhage is granted. ____________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs