Citation Nr: 21065649 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 17-62 117A DATE: October 27, 2021 ORDER Service connection for residuals of a transient ischemic attack (TIA) (affecting the right arm and leg), claimed as secondary to service-connected hypertension is denied. FINDING OF FACT The preponderance of the evidence weighs against finding that there have been any residual effects of a TIA during the appeal period. CONCLUSION OF LAW The criteria for service connection for residuals of a TIA have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Air Force from December 1966 to December 1978 and the Army from October 1981 to February 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran subsequently submitted a request for a hearing before the Board in December 2017 (i.e., VA Form 9). The Veteran gave testimony in a hearing held before the undersigned Veterans Law Judge in April 2020. See 38 C.F.R. § 20.704 (e) (2019). A transcript of this hearing is of record. The Board remanded this matter in July 2020 for further development. The Board finds that there has been substantial compliance with those remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). Entitlement to service connection for residuals of a TIA (affecting the right arm and leg), claimed as secondary to service-connected hypertension Legal Criteria Service connection will be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303 (d). Service connection requires: (1) the existence of a present disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Factual Background & Analysis The Veteran contends that he suffers from residuals of a TIA which occurred in November 2014. The Veteran underwent a VA examination in November 2017. After reviewing the Veteran's records and examining the Veteran in-person, the VA examiner opined that the Veteran's long-standing service-connected hypertension likely caused or aggravated the Veteran's a TIA. However, the VA examiner determined that there were no current residuals disabilities associated with the Veteran's 2014 TIA based on the Veteran's statements at the time of the examination. The VA examiner reasoned that TIAs are, by definition, transient. Thus, TIAs do not produce chronic or lingering residual effects; instead, they cause temporary symptoms. The VA examiner determined that there was no evidence of persisting subjective or objective residuals of the Veteran's TIA. However, the examiner indicated that by CT imaging small vessel ischemic cerebrovascular disease was found and it likely that the Veteran's hypertension significantly contributed to his cerebrovascular disease. In January 2018, the Veteran's private physician provided a medical opinion. Specifically, the private physician opined that the cerebral changes revealed by the CT imaging might have occurred with the Veteran's symptoms in 2014 and that without the Veteran having undergone similar imaging in 2014 to determine whether there were cerebral changes caused by the TIA, it would be very difficult to prove. During an April 2020 Board hearing, the Veteran testified that since the 2014 TIA, he experiences dramatic fatigue, forgetfulness, and growing numbness in his feet. Consistent with the Veteran's testimony, an April 2020 statement by the Veteran's private physician notes that the Veteran has experienced several cognitive changes since the 2014 TIA, to include inability to sustain cognitive focus and short-term memory loss. In July 2020, the Board remanded this matter for a reexamination to determine if there are current residuals of a TIA. In October 2020, in lieu of an in-person examination, a VA staff physician conducted a review of the available medical records in conjunction with a telephone interview of the Veteran due to challenges posed by the COVID-19 pandemic. The report reflects that the Veteran agreed with the examiner's assessment that an in-person examination was unnecessary to resolve the questions of whether the Veteran exhibited any residual effects from the TIA during any portion of the appeal period. The examiner initially noted that the Veteran was admitted to a hospital in November 2014 with right sided numbness and weakness and that CT imaging was negative for a stroke. The discharge summary clearly noted that these symptoms resolved prior to discharge and the Veteran was assessed as having a TIA. The examiner explained that, by definition, a TIA has no residual effects because if they are present then this condition is labeled a stroke. Further, with respect to the CT imaging showing "atrophy and findings consistent with small vessel ischemic disease," the examiner emphasized that there is "no clinical correlation" between these common imaging findings and the Veteran. She elaborates further that small vessel ischemic disease noted on brain imaging is a common and usually asymptomatic finding in individuals over the age of 60, particularly those with vascular risk factors, such as the Veteran. This condition does not require any treatment and has never caused the Veteran any physician symptoms, brain conditions, or dysfunction. The Board in its prior remand had also asked the examiner also to comment on whether the Veteran's claimed symptoms, to include fatigue, cognitive problems, and numbness in his feet are due to or aggravated (worsened beyond the natural progression) by the Veteran's small vessel ischemic cerebrovascular disease. The examiner noted that soon after the TIA in November 2014 the Veteran returned to playing racquetball and that there is otherwise no evidence to suggest that he experiences fatigue as a symptom of TIA. With respect to cognitive problems, the Veteran was noted to have reported difficulties with the inability to recall the names of friends and family and that he was concerned this was a possible "late effect" of his TIA. The examiner explained that TIA does not have late effects and that the Veteran's concerns about "name finding" are not evidence of a pathologic cerebrovascular condition or dementia and are not attributable to TIA. Name finding difficulties were noted to be a very well-known sign of normal aging. Finally, the examiner noted that the Veteran's reported foot numbness are attributable to his service-connected diabetes as diabetic neuropathy. This has been confirmed with a subsequent VA examination in May 2021 and the Veteran has since been service-connected for diabetic neuropathy of the bilateral lower extremities. Moreover, the examiner noted the Veteran's concerns that his "stroke prevention" medications had been escalated, explaining that this was just a preventative measure given his risk factors for stroke of diabetes, hypertension, hyperlipidemia, and the prior TIA. The physician further indicated in an accompanying medical opinion that the Veteran has no symptoms of a small vessel ischemic cerebrovascular disease and therefore no symptoms could be aggravated by this disability. This condition was an imaging finding only with no clinician manifestations. Moreover, as there are no symptoms or residual effects of TIA, there can be no aggravation beyond the natural progression by service-connected hypertension. After a careful review of the evidence the Board finds that the most probative medical evidence weighs against finding that the Veteran has had residual effects of TIA or symptoms attributable to small vessel ischemic cerebrovascular disease during the appeal period. The October 2020 VA physician's findings demonstrated a thorough review of the medical evidence and was completed following an interview with the Veteran. The examiner cited to medical principles and provided a detailed and thorough rationale in determining that the Veteran has not had residual effects of a TIA during the appeal period. Further, the Veteran's reported fatigue, cognitive problems, and numbness in his feet were all attributed to causes or disabilities that are unrelated to a TIA or small vessel ischemic cerebrovascular disease, and well-reasoned alternative explanations were given for each symptom. In sum, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the most probative medical evidence demonstrates that the Veteran has had no residual effects of a TIA during the appeal period or symptoms attributable to small vessel ischemic cerebrovascular disease. Therefore, the first element required for a successful claim for service connection, that the evidence reveal a disability during the appeal period, has not been met. As such, the service claim cannot be successful, and the claim must be denied. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kyle McKone 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.