Citation Nr: 21065102 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 15-39 077A DATE: October 25, 2021 REMANDED Service connection for transient ischemic attacks (mini strokes) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to January 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for ischemic heart disease and mini strokes. The Veteran appealed this rating decision with an August 2014 notice of disagreement. The RO issued a statement of the case in October 2015 and the Veteran perfected his appeal with a VA Form 9 later that month. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in January 2019. A transcript of the hearing is associated with the claims file. In May 2019, the Board dismissed the issue of service connection for heart disease pursuant to the Veteran's withdrawal at his January 2019 hearing, and remanded the remaining issue of service connection for transient ischemic attacks (mini strokes) for further development. In October 2020 and April 2021, the Board again remanded this case for further development. Service connection for transient ischemic attacks (mini strokes) is remanded. Unfortunately, another remand is necessary in this case. The May 2021 VA addendum opinion found that there was no medical evidence that the Veteran's TIAs were permanently aggravated by his PTSD. The Board notes that permanence of aggravation is not required to support a theory of secondary service connection under 38 C.F.R. § 3.310 (b). See Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019). As a result, the rationale provided in the May 2021 VA addendum opinion is insufficient to deny the Veteran's claim. Nevertheless, the record does not contain a positive medical nexus opinion upon which the claim may be granted on a secondary basis. Thus, further development is necessary to ensure the decision on the Veteran's claim is fully informed. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician (other than the November 2020 clinician who provided the etiology opinion) regarding whether the Veteran's transient ischemic attacks (TIAs) are at least as likely as not (a degree of probability of 50 percent or higher) caused or aggravated by service-connected PTSD. The clinician must address causation and aggravation separately. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression; there is no requirement that such aggravation be permanent. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. The clinician must address the significance, if any, of the article submitted by the Veteran in January 2019 that discusses the relationship between PTSD and cerebral vascular disease. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.