Citation Nr: 18156849 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-39 902 DATE: December 11, 2018 REMANDED Entitlement to service connection for chronic fatigue syndrome, to include as due to service in Southwest Asia and/or exposure to hazardous materials, is remanded. Entitlement to service connection for a cerebral aneurysm, to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1990 to April 2010, with documented service in Southwest Asia. Entitlement to service connection for chronic fatigue syndrome The Veteran contends that he has chronic fatigue syndrome that is attributable to his service in Southwest Asia. Specifically, he asserts that he developed the condition either in service or following his discharge from service and that it is due to his exposure to Gulf War environmental hazards. The Veteran was afforded two associated VA examinations in February 2016 to evaluate the nature and etiology of the purported chronic fatigue syndrome. In an examination that focused specifically on Gulf War undiagnosed illness claims, the examiner detailed that the Veteran was treated for chronic fatigue symptoms associated with chronic sleep disturbance in service and that the symptoms have continued to the present. The examiner also found that there was no etiology established for these symptoms and that the symptoms were manifestations of a chronic undiagnosed illness. No rationale was offered for this opinion; strangely, however, the examiner acknowledged that the onset of fatigue symptoms was associated with sleep disturbance in service, and were not associated solely with Persian Gulf deployment. In an Chronic Fatigue examination administered by the same examiner and also dated in February 2016, the Veteran reported that he began to experience fatigue symptoms during service at a time when he was on duty for several hours concurrently. According to the Veteran he still experienced chronic fatigue and was only able to sleep for a few hours each night. The examiner acknowledged that the Veteran experienced chronic sleep disturbance, and noted that the lack of sleep resulted in cognitive impairment in the form of poor attention, inability to concentrate, and forgetfulness. However, after reviewing the claims file and detailing the lack of any symptomatology not attributable to the Veteran’s documented chronic sleep disturbance, the examiner declined to diagnose chronic fatigue syndrome, finding that the Veteran did not meet the criteria for such a diagnosis. The February 2016 VA examiner contradicted himself when he detailed in the Gulf War examination report that the Veteran was treated for chronic fatigue symptomatology in service that continued to the present, but concurrently determined that the Veteran currently did not meet the criteria for a diagnosis of chronic fatigue syndrome. Beyond this apparent confusion, the Board also notes that there is no evidence of any treatment for fatigue symptomatology in service as the examiner stated, calling into question the examiner’s conclusions. Moreover, the examiner provided no rationale for the determination that the Veteran did not have chronic fatigue syndrome. These matters should be clarified in the context of a new VA examination with a rheumatologist and/or immunologist. Entitlement to service connection for a cerebral aneurysm The Veteran contends that he developed a cerebral aneurysm in service manifested by chronic headaches, the residuals of which he currently experiences. In the alternative, he asserts that he developed an aneurysm after service that is secondary to his service-connected headache condition. The etiology of the cerebral aneurysm was evaluated by a VA examiner in May 2016. After reviewing the claims file, the examiner opined that it was less likely than not that the aneurysm was incurred in service or was otherwise attributable to service. In support thereof, the examiner noted that the aneurysm was first discovered unexpectedly via an MRA examination in May 2011 administered for the purposes of treating the Veteran’s headache condition. The examiner detailed that intracranial aneurysms are caused by a congenital defect in the wall of a blood vessel, meaning that the defect is present at birth and therefore not caused by any other condition, including migraine-type headaches. This defect results in weakness in a tiny portion of the arterial wall, with blood coursing through vessels exerting pressure. Eventually, the effect of blood pressing against the tiny weakened portion of a congenitally defective artery may cause a dilation or ballooning to occur, which is called an aneurysm. The examiner highlighted the fact that the Veteran’s mother had a known cerebral aneurysm, and the most likely cause of the Veteran’s cerebral aneurysm was the fact that he had a family history in a first-degree relative. The Board finds this opinion inadequate for a number of reasons. To begin, the May 2016 VA examiner determined that the cerebral aneurysm was congenital in nature, which raises the possibility that the condition preexisted service. On remand, the Regional Office must obtain an opinion as to the likelihood that the cerebral aneurysm preexisted service, and if so, whether it was nevertheless aggravated permanently by an event or injury in service. In addition, although the May 2016 examiner set forth an opinion dismissing the likelihood that the headache condition proximately caused the aneurysm condition, they did not opine as to whether the cerebral aneurysm was aggravated by the headache condition. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). This must be corrected on remand with an addendum opinion responsive to the issue of aggravation. Finally, the Board can find no opinion in the claims file that addresses the likelihood of service connection for the cerebral aneurysm on a direct basis. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA medical examination with a qualified rheumatologist and/or immunologist to address the nature and etiology of his claimed fatigue symptoms. The examiner must review the claims file and address the following matters: A) First, please note whether the Veteran has a medically unexplained chronic multisymptom illness corresponding to the claimed fatigue symptoms. B) If the answer to (A) is negative, please describe whether the Veteran’s reported fatigue symptoms have at the present time or at any time during the pendency of this appeal been chronic in nature and thus would constitute a qualifying chronic disability under 38 C.F.R. § 3.317(a)(2)(i)(B). If this question is answered in the negative, an explanation for this determination is needed. C) If a chronic disability is found to correspond to the fatigue symptoms, please address the possible etiologies of such chronic disability. For any chronic disorder, an opinion should be provided as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder is etiologically related to service. Of particular importance, please address the likelihood that any chemical exposures in Southwest Asia contributed to cause the onset of symptoms. If a chronic disability is found to be attributable to a supervening condition or event that occurred between the Veteran’s most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness, the examiner should so state. If, on the other hand, the examiner is not able to pinpoint the etiology of any such chronic symptoms based on the evidence of record, the examiner should also so state. All opinions must be supported by a rationale. 2. Provide the claims file to the May 2016 VA examiner, or, if not available, to another qualified examiner, in order to elicit an addendum opinion regarding the etiology of the cerebral aneurysm. The entire claims file, including this REMAND, must be made available to this individual. To begin, the examiner must first set forth an opinion as to whether the currently diagnosed cerebral aneurysm clearly and unmistakably preexisted service, and clearly and unmistakably did NOT worsen beyond natural progression during service. Regardless of whether there is this required clear and unmistakable evidence to satisfy the two-prong analysis, i.e., to establish the preexistence of the cerebral aneurysm and that it was not aggravated during or by the Veteran’s service beyond its natural progression, then alternatively consider whether it is it at least as likely as not (a 50 percent probability or higher) that the cerebral aneurysm had its onset during service or is otherwise related to active service. In addition, irrespective of the answer to the above, the examiner is also requested to provide an opinion as to whether it is at least as likely as not that the cerebral aneurysm was caused or aggravated by one or more service-connected disabilities (as listed in a September 2018 rating decision). The examiner should note that the term “aggravated by” refers to a chronic or permanent worsening of the underlying condition, as contrasted to mere temporary or intermittent flare-ups of symptoms that resolve and return to the baseline level of disability. If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated the cerebral aneurysm, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. The examiner must provide any and all opinions as to etiology in the form of a probability, and must provide a complete rationale for any opinion expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Christopher M. Collins, Associate Counsel