Citation Nr: 21061918 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 17-49 217 DATE: October 5, 2021 ORDER Service connection for hypertension is denied. Service connection for seizure condition is denied. FINDINGS OF FACT 1. The Veteran's hypertension did not have its onset in service, did not manifest to a compensable degree within one year of discharge, and is not otherwise causally related to service. 2. The Veteran's in-service seizure did not result in a diagnosed epilepsy or other chronic seizure disorder, no residuals from that in-service seizure have been indicated, and the Veteran does not have a current disability manifested by seizures that is due to any in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. § § 3.102, 3.303, 3.304, 3.306, 3.307, 3.309. 2. The criteria for entitlement to service connection for a seizure condition have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. § § 3.102, 3.303, 3.304, 3.306, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to March 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran timely filed a notice of disagreement (NOD) in December 2015 and a substantive appeal in September 2017. In December 2019, the Board remanded the claims for further development. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air 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) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). 1. Service connection for hypertension The Veteran contends that his hypertension is due to his active military service. He has specifically argued that his hypertension was caused by extreme stress due to his military occupational specialty as an infantry soldier. He also contends that his hypertension and seizure disorder are connected. The term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. or greater, or systolic blood pressure is predominantly 160 or more. 38C.F.R. §4.104, DC 7101 n.1. A diagnosis of hypertension "must be confirmed by readings two or more times on at least three different days." Id. The requirement of multiple blood pressure readings to be taken over multiple days as specified in Note (1) of DC 7101 applies to confirming the existence of hypertension. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). Service treatment records (STRs) reflect that at times during service, the Veteran had elevated blood pressure readings. On May 23, 1977, the Veterans blood pressure reading was 156/80. Another reading from that same day revealed blood pressure of 100/60. On May 24, 1977, it decreased from 140/90 to 120/80. On April 26, 1979, the Veteran was seen following complaint of headache and he requested a blood pressure check. His blood pressure reading was 138/80. On August 21, 1980, the Veteran was seen for a head injury (contusion). His blood pressure reading was 124/78. Post service private medical treatment records from February 2010 indicate a past medical history of hypertension diagnosed in 2007-2008, and that the Veteran started on medication in December 2009. A January 19, 1999 note reflects that the Veteran had a medical history of hypertension. His blood pressure reading was 146/74. An August 2015 VA examination report reflects that the Veteran was treated in service for blood pressure. The clinician found that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. He reported that per his STRs, his blood pressure was normal. There was no record of medications for hypertension. He developed hypertension several years later. He was on medication for the same from the VA. In October 2019 argument submitted by the Veteran's representative, the representative cited medical treatise evidence indicating that preclinical and clinical studies reported in the Neurological Science Journal in September 2019 support the vision that hypertension may be a cause of seizures and epilepsy through direct or indirect mechanisms. He argued that the role of hypertension-related small vessel disease in adult-onset epilepsy has been demonstrated. The representative also cited medical treatise evidence reflecting that seizure activity can cause both a decrease and increase in blood pressure, probably because of stimulation or inhibition of distinct central autonomic function by epileptic activity that propagates into different neuronal networks of the central autonomic nervous system. In a December 2019 VA medical opinion, the clinician found that the claimed hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, he reported that service treatment records were silent for hypertension. He noted that the separation summary revealed a normal blood pressure reading. He reported that past medical history and medications were silent for hypertension. A 2009 VA note reflects a diagnosis of hypertension and he began medication for hypertension. He concluded that his hypertension was diagnosed in 2009, 25 years after leaving military service, and was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The clinician also opined that it is less likely than not (less than 50 percent probability) that hypertension is proximately due to or the result of the Veteran's seizure condition. He noted that hypertension began in 2009 and the one-time seizure activity in May 1977 resolved. He reported that the Veteran was diagnosed with a one-time seizure in May 1977. The work up was negative. He was not on any medications. He was never diagnosed with a chronic seizure condition, so his seizure was resolved without any residuals. He has no seizure disorder per problem list. He began blood pressure medication in 2009. His VA treatment records are silent for a seizure disorder. Finally, the clinician found that the Veteran's hypertension it was not at least as likely as not aggravated by his seizure condition. The clinician could not determine a baseline level of severity as the medical evidence was insufficient. He found that the Veteran's hypertension was not at least as likely as not aggravated beyond its natural progression by seizures. He reported that the Veteran is not in receipt of service connection for seizures. He reiterated that the Veteran was diagnosed with one time seizure in May 1977 and has never been diagnosed with chronic seizure condition, so his seizure was resolved without any residuals. He had a seizure in 1999 and 2000. He had work up that was negative. His diagnosed seizure activity was due to sleep deprivation per local neurology by Dr. Newton. There is no diagnosis of chronic seizures, no medication, and no driving restrictions. He is not on seizure medications. His blood pressure readings were normal during the above hospitalizations. He started blood pressure medication in 2009. He concluded that his hypertension diagnosis on medications since 2009 was not aggravated by his one-time seizure in May 1977, 1999 for which he has no medication, no recurrence, no residuals, and the problem list is silent. VA treatment records reflect that the Veteran began treatment for hypertension in 2009. Upon review of the evidence of record, service connection for hypertension is not warranted. Initially, as noted above, the Veteran was diagnosed with hypertension in 2009. Thus, the question remains as to whether his diagnosis is related to his active military service. The Veteran's hypertension did not have its onset in service and did not manifest to a compensable degree within on year of separation. The Veteran's STRs contain various isolated elevated blood pressure readings as noted above. However, these do not constitute a diagnosis of hypertension. Notably, there were roughly three to four elevated blood pressure readings out of the 10 years that the Veteran was in active military service. As previously noted, VA regulations define hypertension as having the diastolic blood pressure of predominantly 90 mm. or greater, or systolic blood pressure of predominantly 160 or more, which must be confirmed with two or more readings, taken on at least three different days. The Veteran's STRs do not contain such readings. While the Veteran's STRs contain isolated slightly elevated blood pressure readings, there are no records of the Veteran's diastolic blood pressure being recorded at 90 or above two or more times on at least three different days, no systolic blood pressure readings of 160, and there is no hypertension diagnosis. It is a well-established medical principle that isolated elevated blood pressure readings do not, in and of themselves, constitute a diagnosis of hypertension. The Veteran's post-service records do not show a diagnosis of hypertension or consistently elevated blood pressure readings consistent with the VA's definition of hypertension until 2009. The Veteran's VA treatment records indicate that he did not begin consistent treatment for hypertension until 2009, 25 years following separation from service; and, that he wasn't diagnosed with hypertension until 2007 or 2008. Although the Veteran believes that his isolated elevated blood pressure readings during service constitute the onset of hypertension; and/or that his hypertension is otherwise related to service, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Veteran's lay assertions are afforded no probative value. Based on a review of the available records and his particular expertise, the December 2019 clinician found that the Veteran's hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Additionally, the clinician noted the Veteran's arguments that there was a connection between his hypertension and seizure and provided an adequate rationale for his conclusion that the Veteran's disability was not due to service and was not caused or aggravated by his one seizure in service. As the clinician explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Regarding the medical literature submitted by the Veteran, medical article and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). However, treatise materials are generally not specific enough to show nexus. Id. Moreover, medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). In this case, regardless of the specificity of the treatise evidence submitted, its probative value is outweighed by the specific, reasoned opinion of the December 2019 VA clinician. See Nieves-Rodriguez, 22 Vet. App. at 304 (most of the probative value of a medical opinion comes from its reasoning. Cf. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (a medical opinion that relies on the absence of general medical literature supporting nexus without discussing the specific facts of the case is inadequate). Notably, the medical treatise submitted addressing hypertension mostly argues that seizure causes hypertension. As will be clarified in further detail below, the Veteran had one seizure in service. The medical treatise submitted speaks largely about epilepsy, which is a diagnosis that the Veteran does not have. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for hypertension. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Service connection for seizure condition The Veteran contends that his seizure condition is due to his in-service seizure. Service treatment records reflect that on May 23, 1977, the Veteran was admitted to the emergency room due to seizure. He was in his usual state of health when he developed a severe headache and became slightly dizzy. He gave the wheel of the car to his friend and a few moments later, developed what was described as a grand mal seizure. He was brought to the ER at which time he had recovered somewhat but was still disoriented. The clinician noted an impression of ataxia status post syncope, headache, and disorientation. The plan was to obtain a lumbar puncture. A spinal tap was unrevealing. At this date, the Veteran complained of headache only. On May 24, 1977, there was no distress, and the Veteran was oriented. An examination of his head, neck, heart, lungs, and abdomen was normal. His speech was normal, cranial nerves intact, muscle strength normal, and his sensory nervous system was not impaired. The clinician noted a negative neurological examination. A brain scan and skull films were requested due to a "first time seizure." The initial impression was epilepsy. On May 27, a brain scan and skull films were noted as within normal limits. From May 24 to May 27, 1977, the Veteran was monitored with no seizure activity. He was discharged on May 27, 1977. The clinician noted that the seizure etiology was undetermined as they were awaiting an electroencephalography (EEG). A June 1977 EEG report was normal. There was no evidence of focal or paroxysmal abnormalities. The psychomotor variant was considered a normal variation in pattern and was to be distinguished from psychomotor epilepsy. A normal EEG does not rule out the possibility of a seizure disorder. A clinical correlation was needed. There were no further notations regarding the seizure. In January 1999, the Veteran was treated at a private emergency room for a chief complaint of seizure activity. He was admitted with a new onset seizure. The diagnosis on discharge was seizure disorder. He reported complaints of nausea, abrasion to right eyebrow, and right eyelid reddened. His neurological examination was normal. The CAT scan of the brain was normal. An EKG revealed a sinus rhythm. The clinician noted that the description of his seizure went along with a generalized tonic clonic seizure. The Veteran had an MRI and EEG that was normal. Before the seizure occurred, there was no headache, focal weakness, numbness, speech, visual changes, or any problems at all. He reported that he was just lying in bed dozing off to sleep. He reported that there was no history of any prescription or illicit drug use, and he indicated that he did not want to take Dilantin. He reported that he had a similar episode 20 years ago on an Army Base in Louisiana. He reported that he was told he had a seizure at that time, but never had any anti-epileptic long-term therapy. He reported that both of these episodes were associated with sleep deprivation. He reported that he is a security guard, and he has been working a lot of long hours recently. His physical and neurological examination was normal. The clinician noted that the Veteran had a seizure disorder and reported it is clearly what was described as generalized tonic/clonic seizure. It was noted he has been working a lot of long hours and sleep deprivation may be the cause. He reported that his seizure 20 years ago was related to sleep deprivation as well. He reported that it is possible if he just gets his sleep on a regular basis he will not have any seizures either. He did not want to go on Dilantin, a seizure medication. Thus, seizure precautions were discussed in detail with the Veteran, and he was told that Alabama law does not allow him to drive six to 12 months after having a seizure. In September 2000, the Veteran was seen at St. Vincent's Hospital and reported that he had a seizure. He reported a very slight headache and a toothache for approximately three days. He had no complaints at that time. He reported he had a seizure while in the Army approximately 25 years ago and in January 1999 had another seizure. He was evaluated at that time and his wife reported that it was the conclusion at that time that it was perhaps sleep deprivation induced in that the Veteran was working 16 hour shifts at the time of that procedure. She reported that no medications were prescribed. The clinician noted that the Veteran was doing well until the seizure in September 2000. The impression was seizure. The Veteran was told to rest for 24 hours, take Dilantin two times per day, and no driving. Radiology report revealed that the brainstem, cerebellum, and cerebral hemisphere appear normal without intra cerebral hemorrhage, mass defect, or midline shift. Impression was negative non contrasted cranial CT. The Veteran was discharged from the hospital with no medication. The cilician noted that the seizure was felt to be secondary to sleep deprivation. A December 2000 follow up reflects that a review of the Veteran's chart revealed a seizure with a negative CT. He had a history of normal scans. After his seizure in 1999, he was started on diphenhydramine (seizure medication). He was seen by Dr. Newton a month ago. A current CT of the head was negative. His medical history included using the medication Dilantin. In his December 2015 notice of disagreement (NOD), the Veteran reported that he suffered from a seizure disorder while in service. An October 2019 appellate brief reflects that the Veteran's representative cited medical treatise that reflect that current evidence from preclinical and clinical studies reported in the Neurological Science Journal in September 2019 support the vision that hypertension may be a cause of seizures and epilepsy through direct or indirect mechanisms. The role of hypertension-related small vessel disease in adult-onset epilepsy has been demonstrated. The representative cited medical treatise that reflects that seizure activity can cause both a decrease and increase in blood pressure, probably because of stimulation or inhibition of distinct central autonomic function by epileptic activity that propagates into different neuronal networks of the central autonomic nervous system. Additionally, he reported that medical treatise shows that epilepsy from a scar can lay dormant for many years. An August 2015 VA examination report reflects a diagnosis of seizure, in 1977. The physician reported that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The physician specifically indicated that continuous medication was not used to control seizures and that he had no other treatment for seizures. The examiner also noted that while the Veteran did have a witnessed seizure, a diagnosis of a seizure disorder had not been confirmed; and, the Veteran did not have a diagnosis of epilepsy with a history of seizures. The Veteran was diagnosed with a seizure in May 1977 with a negative work up. He was not on any medications. He was seizure free for about 22 years after that. He later developed a seizure in 1999 and 2000 per private medical records. The work up was negative. The physician noted that per Dr. Newton in neurology, the seizure activity was related to sleep deprivation. The Veteran was not treated with any medications and there was no more seizure activity. In a December 2019 VA addendum medical opinion, the same physician again found that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, he reported that during the pendency of the claim, the Veteran did not have a seizure condition or epilepsy. He reported that the Veteran was diagnosed with one time seizure in May 1977 with a negative work up. He was not on any medications. The clinician noted that he was never diagnosed with a chronic seizure condition, so his seizure was resolved without any residuals. He reported that the Veteran had a seizure in 1999 and 2000 with a negative work up. He was diagnosed with seizure activity due to sleep deprivation. There was no diagnosis of chronic seizures, no medication, and no driving restrictions. He reported that his VA treatment records are silent for a seizure disorder. He reported that his seizures were less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's hypertension. As rationale, he reported that hypertension was postdated to 2009 and his seizure activity was in May 1977 with resolution. There was no blood pressure treatment until 2009. The clinician reported that he was unable to determine a baseline level of severity of the Veteran's seizure condition as the medical evidence was insufficient. He found that the Veteran's hypertension was not at least as likely as not aggravated beyond its natural progression by hypertension. As rationale, he reiterated that he was never diagnosed with a chronic seizure condition and his seizure was resolved without any residuals. He reported that the seizure activity in 1999 and 2000 were due to sleep deprivation. He noted that the VA treatment records do not show a diagnosis of a seizure disorder. A review of the VA treatment records reflect that the Veteran did not have a current diagnosis of a seizure disorder and has not had a seizure since 2000. He was also not on any medication for seizures. He has not submitted any private treatment records showing that the Veteran has been on any treatment or medication for seizures or preventing them. Upon review of the evidence of record, service connection for a seizure disorder is not warranted. The weight of the above evidence does not indicate the presence of a current seizure disorder during the pendency of the claim. See 38 U.S.C. § 1701 (1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing "eligibility for disability compensation for service-connected disabilities"). There is no medical evidence of a seizure disorder or any current symptoms thereof. As such, entitlement to service connection is not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) ("Without a current disability, of course, there can be no service connection and, thus, no disability compensation"). The December 2019 VA medical opinion explained how the clinician concluded that the Veteran's seizures have resolved, and that the Veteran did not have a current diagnosis of a seizure disorder. Specifically, he reported that the Veteran's 1999 and 2000 seizure disorders were tied to a lack of sleep as noted by the clinicians at that time. He noted how all of the workups following the Veteran's seizures, to include in service, have been normal and have not shown a seizure disorder. Notably, the Veteran's last seizure was in 2000 which was 15 years before the Veteran filed his claim for service connection for a seizure disorder in May 2015. Additionally, a review of the VA treatment records reflect that the Veteran has not complained of any seizure related symptoms, has not taken any medication for seizures, and has not had a seizure throughout the entire period on appeal. As the clinician explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The preponderance of the evidence shows that the Veteran's seizures were isolated events related to his lack of sleep. They have since resolved, and the physician explained that there was no current chronic seizure disorder, the Veteran was not an epileptic, and no medication was necessary to stop seizures. Although the 1999 medical records indicate a history of "seizure disorder," that indication was based on a single seizure in 1977 and a subsequent seizure in 1999. The VA physician in 2015 and 2019 specifically addressed each of the three seizure events, including the 1999 seizure and treatment therefor, and specifically found that the totality of the evidence was against a finding of a chronic seizure disorder or epilepsy. As this finding is based on an accurate review of the past medical history, which is consistent with the Veteran's reported seizure history, it is accorded higher probative value than the 1999 finding of seizure disorder. Regarding the medical literature submitted by the Veteran. Medical article and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). However, treatise materials are generally not specific enough to show nexus. Id. Moreover, medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). In this case, regardless of the specificity of the treatise evidence submitted, its probative value is outweighed by the specific, reasoned opinion of the December 2019 VA clinician. See Nieves-Rodriguez, 22 Vet. App. at 304 (most of the probative value of a medical opinion comes from its reasoning. Cf. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (a medical opinion that relies on the absence of general medical literature supporting nexus without discussing the specific facts of the case is inadequate). Notably, one of the facts from the medical treatise submitted by the Veteran's representative notes that some people require lifelong treatment to control seizures, but for others, the seizures eventually go awayas is the case with the Veteran. The medical treatise also reported that epilepsy from a scar can lay dormant for many years; however, none of the radiology imaging reports indicate that the Veteran had any brain abnormalities or scars related to a seizure, and he has never been diagnosed with epilepsy. Another article reflects that a normal EEG does not rule out the possibility of seizure disorder; however, the Veteran underwent numerous other testing that was all normal; and, to date, this Veteran does not have a diagnosed seizure disorder related to service. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a seizure disorder. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laroche, N. 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.