Citation Nr: 20076902 Decision Date: 12/03/20 Archive Date: 12/03/20 DOCKET NO. 13-06 395A DATE: December 3, 2020 ORDER Entitlement to service connection for residuals of stroke, to include as secondary to service-connected coronary artery disease disability is denied. FINDING OF FACT The Veteran’s residuals of stroke were incurred many years after his separation from his last period of service, and the preponderance of the evidence is against a finding it is due to or aggravated by the Veteran’s service-connected coronary artery disease disability. CONCLUSION OF LAW The criteria for entitlement to service connection for residuals of stroke, to include as secondary to service-connected coronary artery disease disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from October 1969 to February 1974 and from January 1975 to September 1994. 1. Entitlement to service connection for residuals of stroke, to include as secondary to service-connected coronary artery disease disability The Veteran asserts that he has suffered strokes as secondary to his service-connected coronary artery disease disability. Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Establishing service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In order to establish secondary service connection, the record must contain: (1) a current disability that is not already service-connected; (2) at least one service-connected disability; and (3) evidence that the non-service-connected disability is either proximately due to or the result of a service-connected disability; or, aggravated (increased in severity) beyond its natural progress by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran does not assert, and his service treatment records do not show, that he suffered from stroke during his period of service. Moreover, there is no competent medical evidence that links the Veteran’s current residuals of stroke to his period of service. The competent evidence of record does not demonstrate that service connection for residuals of stroke is warranted on a direct basis. See 38 C.F.R. § 3.303. The Board turns to the Veteran’s primary assertion that he suffered a stroke as secondary to his service-connected coronary artery disease. However, the Board finds that the weight of the probative evidence is against such a finding. The diagnostic evidence in October 2007 first demonstrated that the Veteran suffered from old lacunar pontine stroke in the right pontine, and it was felt that the Veteran experienced focal dystonia of the left upper extremity secondary to the stroke. See October 2007 to January 2008 private vascular and neurology consultation records; see also February 2020 VA medical opinion report. Private treatment records show the Veteran was hospitalized for two transient ischemic attacks (TIA) in June 2008, and the Veteran was started on medication. Later, private and VA medical records indicate that those June 2008 incidents were likely syncopal episodes and not additional TIA/strokes as diagnostic testing completed, to include heart catheterization, carotid doppler, showed no significant coronary artery disease. See August 2008 private vascular neurology consultation and February 2020 VA examination report. Next, an October 2012 VA vascular laboratory report noted that diagnostic testing showed symptomatic carotid stenosis with recent TIA/Stroke, it is not clear from record whether the findings referred to previous TIAs or a more recent attack. Subsequent VA treatment records do not show any additional TIA, and only reflect that the Veteran continued to take medication to prevent strokes. A February 2020 VA central nervous system and neurovascular disease examination report showed that the Veteran complained of intermittent muscle spasms in upper left arm and burning sensation in left hand as residuals of his stroke. However, the VA examiner found that the clinical evaluation did not reveal objective findings to support a central nervous system diagnosis, despite the Veteran’s subjective complaints. Here, the diagnostic evidence of old lacunar pontine stroke in October 2007 and competent medical evidence has associated focal dystonia of the left upper extremity as secondary to that stroke. Although it remains unclear from the competent medical evidence whether the Veteran suffered any additional TIA/stroke during the pendency of the claim or recent to the filing of the claim, given the Veteran’s subjective complaints as well as continuation of his medication to prevent strokes, the Board finds that evidence demonstrates a current disability of residuals of stroke. The Board concludes that, while the Veteran has a current disability due to residuals of stroke, the preponderance of the evidence weighs against finding that the Veteran’s residuals of stroke are proximately caused or aggravated by his service-connected coronary artery disease disability. In a February VA medical opinion report, the VA examiner concluded that the Veteran’s stroke was less likely than not proximately due to or result of service-connected coronary artery disease disability. The VA examiner noted that lacunar strokes are the most common type of ischemic stroke, resulting from occlusion of small penetrating arteries that provide blood to the brain. Lacunar stroke may result from carotid artery pathology or micro-emboli from the heart. However, a review of the diagnostic testing completed in 2008 (one year following discovery of old stroke), to include heart catheterization and carotid doppler, showed no significant coronary artery disease. The VA examiner found that the Veteran’s lacunar stroke was considered incidental finding on the imagining, with no objective evidence of sequelae, and concluded that there was no nexus or plausible secondary relationship to his service-connected coronary artery disability. In addition, in a June 2020 addendum to the February 2020 VA medical opinion report, the VA examiner concluded it was less likely than not that the Veteran’s residual of stroke was aggravated beyond its baseline due to his service-connected coronary artery disease disability. In this regard, the VA examiner noted that the Veteran’s residual of stroke baseline was manifested by focal dystonia of the left upper extremity as reflected in the 2007 and 2008 private vascular neurology consultation reports. The VA examiner stated that he was unable to find a current diagnosis of stroke based on review of the Veteran’s medical records and findings from clinical evaluation. Rather, the VA examiner found that the evidence of equal and symmetrical abnormalities noted on physical examination are due to unrelated medical conditions, to include the Veteran’s non-service connected neck disability and service-connected physical disabilities involving his lumbar spine, upper extremities, and lower extremities. The VA examiner concluded that the Veteran’s current level of severity was not greater than established baseline as there was no pathophysiology to support a mechanism for aggravation. The Board finds that the VA examiner’s opinions have adequately considered and addressed secondary service connection as due to coronary artery disease and discussed aggravation. The examination report and rationale cited to medical evidence of record that are sufficient to support the opinions. The opinions considered the Veteran’s service-connected conditions and lay reports contained within his record. The VA examiner found that the evidence of record established a pre-aggravation baseline which was not aggravated by his service-connected coronary artery disability. Consequently, the Board finds the VA medical opinion to be highly probative weight against the claim. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000). There is no contrary medical opinion of record. The Veteran believes his residuals of stroke is proximately due to or the result of and/or aggravated beyond its natural progression by service-connected coronary artery disease disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the above, the Board finds that the Veteran’s residual of stroke was not related to service, to include as proximately due to or aggravated by service-connected coronary artery disease disability. Service connection is also not warranted for residuals of stroke as a chronic disability under 38 C.F.R. § 3.307 (a), as the competent medical evidence of record does not demonstrate that the Veteran’s stroke was noted as chronic in service or manifested to a compensable degree in service or within the one year presumptive period. See 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Medical evidence does not reveal that the Veteran had a formal diagnosis of stroke until many years after separation from service. Moreover, the Veteran has not asserted that he suffered residuals of stroke since service. For this reason, the Board finds that an opinion regarding nexus was required to establish this element of the claim, and unfortunately, the opinion evidence weighs against service connection. As the evidence weighs against a finding that residual of stroke is caused by or incurred in service or, alternatively, proximately due to or aggravated by service-connected disabilities described above, the claim must be denied. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Murray, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.