Citation Nr: 18153071 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 14-25 097 DATE: November 27, 2018 REMANDED Entitlement to service connection for a traumatic brain injury (TBI), claimed previously as brain trauma is remanded. REASONS FOR REMAND The Veteran served honorably on active duty with the United States Army from March 1979 to October 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was most recently before the Board in July 2016, at which time the Board, inter alia, denied the claim of entitlement to service connection for TBI. The Veteran appealed the decision to the Court of Appeals for Veterans’ Claims (Court). In an April 2018 Memorandum Decision, the Court vacated the Board’s April 2018 decision and remanded the appeal for further action.   Entitlement to service connection for a traumatic brain injury (TBI), claimed previously as brain trauma, is remanded. In the April 2018 Memorandum Decision, the Court determined that the Board failed to provide an adequate statement of reasons or bases for its denial of service connection for TBI, and that it relied on inadequate VA examination reports. The Court found that the VA opinions provided in November 2010 and May 2011 are inadequate. The November 2010 examiner concluded that the Veteran did not have a current diagnosis of TBI and that his current neurological symptoms did not have an onset during service, nor was there any documentation of head trauma during service that caused neurological deficits. However, the examiner failed to acknowledge potentially positive evidence of record, such as a March 2010 brain MRI showing old chronic changes due to a head injury or an April 2010 neuropsychological study showing cognitive impairment and TBI diagnosis. The May 2011 examiner provided an extensive review of the Veteran’s medical history but did not provide any opinion as to whether the Veteran has a TBI, and if so, whether it is related to service. The Court found the Board’s reliance on these examination reports to be improper and directed that the Veteran be afforded a new VA examination. Accordingly, the appeal is remanded for such action. Accordingly, the matter is REMANDED for the following action: 1. Obtain and associate with the claims file any updated medical treatment records. 2. Then, arrange for the Veteran to undergo a VA TBI examination with an appropriate examiner to determine the nature and etiology of his claimed TBI/residuals of head trauma. The Veteran’s claim file should be made available to the examiner prior to the examination. The examiner must review the entire claim file in conjunction with the examination. The examiner should conduct all necessary tests and studies. Following review of the record and examination, the examiner must address the following: (a.) Is it at least as likely as not (at least a 50 percent probability) that the Veteran sustained a TBI in service due to a head injury or injuries? In answering this question, the examiner is advised that the record reflects that the Veteran fell and hit his head on a bed rail during service in 1984, causing him to lose consciousness for an unknown period of time, possibly days. On a separate occasion close in time, he had a beer bottle broken over his head but did not lose consciousness. (b.) Is it at least as likely as not that any current residuals associated with head trauma were caused by or resulted from the injury or injuries sustained during the Veteran’s active duty service? The opinions provided must be accompanied by a thoroughly explained rationale. The examiner is asked to specifically address any potentially positive evidence of record, to include the March 2010 brain MRI showing old chronic changes due to head injury, the April 2010 neuropsychological study showing cognitive impairment and TBI diagnosis, the August 2010 TBI evaluation suggesting the Veteran’s claimed in-service injury and symptoms were consistent with a diagnosis of TBI and the August 2010 opinion from Dr. West. The examiner is further advised that a succinct chronological review of the relevant medical examinations was provided by the Court in its October 2018 Memorandum Decision, which may be useful. If the examiner is unable to reach any of the opinions requested above without resort to speculation, he or she should explain the reasons for that inability and comment on whether further tests, evidence, or information would be useful in rendering the requested opinion. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. T. Raftery, Associate Counsel