Citation Nr: 18150600 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-30 187 DATE: November 15, 2018 ORDER Entitlement to service connection to cerebrovascular accident secondary to obstructive sleep apnea is granted. FINDING OF FACT The evidence is at least in relative equipoise as to whether the Veteran’s cerebrovascular accident is secondary to his service-connected obstructive sleep apnea. CONCLUSION OF LAW The criteria for cerebrovascular accident secondary to obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army from January 1981 to January 2001. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an October 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. Cerebrovascular Accident secondary to Obstructive Sleep Apnea Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In May 2013, the Veteran was diagnosed with a CVA (ischemic stroke). In addition to a comprehensive examination at the VA, the Veteran was seen, treated, and examined by many different physicians with qualifications and specialties in different areas of medicine. While every physician who treated or examined the Veteran agreed that the Veteran was properly diagnosed with CVA with residuals, there are two competing medical opinions as to etiology. In July 2013, three months after the Veteran’s CVA, Dr. A.R. diagnosed the Veteran with OSA with a secondary diagnosis of a stroke. Dr. A.R. pointed out that the Veteran has severe OSA that is manageable with a continuous positive airway pressure (CPAP) machine but that his “stroke deficits” would not resolve. A September 2015 VA examination recorded that the Veteran’s speech was abnormal with difficulty finding some words but with good comprehension. It was also noted that the Veteran’s muscle strength was normal but there were decreased deep tendon reflexes. The examiner stated that the Veteran has mild expressive aphasia as a residual of the stroke, but noted that the previous physicians could not pinpoint the cause of the Veteran’s CVA. The examiner did not state what caused the Veteran’s CVA, but noted that strokes, in general, are caused by an interruption of blood flow causing infarction of a brain area. It was also noted that OSA does not cause vascular diseases or predispose an individual to a stroke and that OSA is not medically recognized as a cause or risk factor for a stroke. In a November 2015 letter, Dr. A.R. opined that the Veteran’s “long history of severe obstructive sleep apnea almost definitely contributed to the stroke that [he] suffered in 2013.” No further explanation was provided. In March 2017 addendum opinion, the above-mentioned VA examiner stated that the cause of the Veteran’s stroke was indeterminant. Speaking in generalities, the examiner noted that a stroke is caused by the interruption of blood flow to the brain tissue for a sufficient period of time to cause cell death and that sleep apnea is not a medically recognized cause of CVA. Instead, the examiner noted that the Veteran’s sleep apnea, and the treatment therefore, would be expected to “increase blood flow to the brain.” He opined that it is unlikely that the Veteran’s OSA worsened his stroke beyond normal progression. In an October 2017 letter, Dr. A.R. reaffirmed his opinion from November 2015. Specifically, after evaluating the Veteran, Dr. A.R. stated that the Veteran’s OSA did not aggravate his stroke, but rather was the cause of the Veteran’s stroke. Dr. A.R. further submitted medical treatise evidence that addressed the issue of OSA causing and/or contributing significantly to CVA. Based on this medical scholarship, his familiarity with the longterm treatment of the Veteran, and his expertise in the field of sleep pathology, Dr. A.R. emphatically stated that the Veteran’s sleep apnea caused or contributed substantially to his symptoms. The Board has the responsibility of weighing the conflicting medical opinions given by Drs. E.U. (VA examiner) and A.R. (non-VA examiner). See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). In weighing evidence, the Board may place greater weight on one physician’s opinion over another depending upon factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. Id.; see Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (stating that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Based upon careful review of the foregoing, the Board finds that the evidence of record pertaining to the etiology of the Veteran’s CVA is at least in relative equipoise. As such, service connection for CVA secondary to the Veteran’s service connected OSA is warranted in this case. 38 C.F.R. § 3.102 (2017); see also 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). M. Donohue Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Jones Council, Associate Counsel