Citation Nr: 20037543 Decision Date: 06/02/20 Archive Date: 06/02/20 DOCKET NO. 11-01 719 DATE: June 2, 2020 REMANDED An initial higher rating in excess of 10 percent for residuals of cerebrovascular accident (CVA).   REASONS FOR REMAND The Veteran served on active duty from December 1968 to December 1972 and from January 1973 to March 1989. The case is on appeal from an August 2010 rating decision. The case was most recently before the Board in April 2018. At that time, the Board, in part, remanded the issues of residuals of CVA for further development and adjudication and the issue of service connection for sleep apnea for the issuance of a Statement of the Case (SOC) pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). A SOC was issued in October 2018 accordingly. However, as the Veteran did not submit a VA Form 9 to perfect his appeal within 60 days from the October 2018 SOC, the issue is no longer before the Board. As such, the only issue remaining is the initial higher rating for residuals of CVA. An initial higher rating in excess of 10 percent for residuals of CVA. In the present case, the Veteran’s residuals of a CVA are rated under the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8008. The regulation provides that special consideration should be given to psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. Partial loss of use of one or more extremities from neurological lesions are to be rated by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves. First, in the April 2018 remand, the Board ordered a new VA examination to specifically assess any existing, or not yet identified or evaluated residuals from a CVA and their severity. Notably, the Board highlighted the Veteran’s and his wife’s statements regarding symptoms which included more than just expressive aphasia and sleep disturbances. In that regard, the Board made reference to a February 2008 private treatment note in which a health provider diagnosed the Veteran with Gerstmann’s Syndrome. Gerstman’s Syndrome is defined as “a combination of finger agnosia, right-left disorientation, agraphia, acalculia, and often constructional apraxia.” See Dorland’s Illustrated Medical Dictionary, 403 (32nd ed. 2012). The Board further highlighted the private note indicating that the Veteran’s stroke in January 2008 was “evidenced by left sided neglect and left hemi numbness.” The Veteran and his wife have also noted various difficulties with his left side extremities, memory loss and other cognitive difficulties. Pursuant to the April 2018 remand, the Veteran was afforded a VA examination in August 2019. The examination report includes a diagnosis of residuals of CVA associated with hypertension. The VA examiner noted that the Veteran has difficulty with talking and remembering things, difficulty with speech and communication, mild swallowing difficulties, and persistent daytime hypersomnolence. The VA examiner also noted that the Veteran presented with antalgic gait, however, attributed to his “generalized pain.” During a September 2018 VA psychiatric evaluation, the VA provider noted that the Veteran’s 2007 and 2008 CVAs resulted in difficulties with speech, writing, “left side weakness, left side chronic pain and numbness with resultant difficulty with ambulation due to weakness.” According to lay evidence received from the Veteran in May 2020, the Board notes that besides the his already service-connected expressive aphasia and sleep disturbances as residuals of his CVA, additional residuals may be manifesting by constant pain and inflammation; shortness of breath; difficulty writing, reading, and retaining information; unsteadiness with multiple falling episodes; inability to sit and stand for too long; inability to walk long distances; painful leg cramps; disorientation problems; inability to climb stairs, irritability and frustration, and isolation from his family. See also September 25, 2018 VA progress notes. In light of the above, the Board notes that the evidence is not entirely sufficient to determine the severity and extent of the Veteran’s claimed residuals at this time. The August 2019 examination report itself reflects little or no assessment of additional symptoms, other than expressive aphasia and sleep disturbances, reported by the Veteran and his wife. The VA examiner also failed to discuss the February 2008 private treatment notes suggesting the Gerstmann’s Syndrome and indicating that the Veteran’s stroke in January 2008 was evidenced by left side neglect and left heminumbness. While the Veteran is service connected for separate disabilities and the reported symptomatology could be related, or attributed at least in part, to any of those disabilities, the August 2019 VA examination report neither clarifies that aspect of the claim. Given the Veteran’s and his wife’s statements attributing additional symptoms to his CVA and evidence of record suggesting other symptoms such as partial loss of his left lower extremity which could be attributed to his service-connected CVA, , the Board finds that another remand is warranted to assess these aspects of the claim. In light of the remand, relevant VA and private treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records dated since March 2020. 2. Request from the Veteran any available private treatment records in connection with this claim. 3. Thereafter, schedule the Veteran for a VA examination (or telehealth interview, records review, etc., if an in-person examination is not feasible) by an appropriate medical professional with respect to the residuals of a CVA. Any clinically indicated diagnostic testing should be performed. The examiner should first identify the severity of the Veteran’s service-connected residuals of a CVA, characterized as aphasia and sleep disturbances. The examiner should then identify or ascertain any additional residuals which may manifest by Gerstmann’s Syndrome, left side weakness, left side chronic pain and numbness with resultant difficulty with ambulation or antalgic gait, unsteadiness, to include falling episodes, and/or irritability, frustration and isolation. If any of the foregoing disabilities is not diagnosed or considered a residuals of the Veteran’s CVA, it should be explained why this is so. For any identified residual(s), the examiner is asked to describe the current extent and severity of all residuals of the Veteran’s CVA. Consideration should be given to: (1) the February 2008 private treatment notes indicating a diagnosis of Gerstmann’s Syndrome; (2) the September 2018 VA treatment notes stating additional residuals from a CVA as noted in the Reasons and Bases portion of this decision; and (3) the Veteran’s and his wife’s statements as to difficulties with his left side extremities, memory loss and other cognitive difficulties. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board William Pagan, Associate 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.