Citation Nr: 21068419 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-57 919 DATE: November 10, 2021 ORDER Service connection for residuals of an aneurysm post brain surgery, to include as secondary to cluster-type headaches, is denied. Service connection for polyneuropathy of the right lower extremity, to include as secondary to the aneurysm caused by cluster-type headaches, is denied. Service connection for polyneuropathy of the left lower extremity, to include as secondary to the aneurysm caused by cluster-type headaches, is denied. FINDINGS OF FACT 1. Residuals of an aneurysm post brain surgery did not manifest on active duty, were not otherwise caused or aggravated by any incidence of active duty; and residuals of an aneurysm post brain surgery were not proximately caused by or aggravated by service-connected cluster-type headaches. 2. Polyneuropathy of the right lower extremity did not manifest on active duty, were not otherwise caused or aggravated by any incidence of active duty; and polyneuropathy of the right lower extremity was not proximately caused by or aggravated by service-connected cluster-type headaches. 3. Polyneuropathy of the left lower extremity did not manifest on active duty, were not otherwise caused or aggravated by any incidence of active duty; and polyneuropathy of the left lower extremity was not proximately caused by or aggravated by service-connected cluster-type headaches. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of an aneurysm post brain surgery have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 3.310 (2020). 2. The criteria for service connection for polyneuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3.310. 3. The criteria for service connection for polyneuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty as a personnel specialist in the United States Army from September 1977 to September 1997. These matters come before the Board of Veterans' Appeals on appeal from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The Veteran's claims file contains a copy of the hearing transcript. In April 2021, the Board remanded these matters for additional evidentiary development. The Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). SERVICE CONNECTION The Veteran asserts that residuals of an aneurysm that required brain surgery, polyneuropathy of the right lower extremity, and polyneuropathy of the left lower extremity were incurred in, aggravated by, or otherwise attributable to service or to service-connected cluster-type headaches. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). In the absence of proof of a present disability there can be no valid claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Competent lay evidence may also include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). In determining whether service connection is warranted for a disability, 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 v. Derwinski, 1 Vet. App. 49 (1990). 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. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Evidence and Analysis Service treatment records (STRs) contain the Veteran's June 1997 retirement report of medical examination. A clinician reported normal evaluations of the head, face, neck, scalp; lower extremities; spine and other components of the musculoskeletal system; and neurological status. In the associated report of history of medical, the Veteran reported that he had not had and did not have dizziness or fainting spells: head injuries; cramps in the legs; trick or locked knees; foot trouble; neuritis; paralysis; epilepsy or fits; loss of memory or amnesia; or any periods of unconsciousness. He did report a history of cluster headaches; however, there is no history or treatment for blast trauma or orthopedic or head injuries due to falls. While the Veteran's other STRs disclose complaints and treatment for cluster headaches, they do not provide any reference to complaints, treatment, or diagnoses indicative of brain aneurysm or polyneuropathy of the bilateral lower extremities. Records of care by a private physician and university health medical center show that the Veteran underwent surgery for a posterior fossa arteriovenous fistula in February 2014. The attending physician noted that the Veteran had a known high cervical vascular anomaly and had been diagnosed in December 2013 after he experienced an acute headache with weakness eventually deteriorating to quadriplegia. The RO received the Veteran's claims for service connection for residuals of brain surgery and peripheral neuropathy of the bilateral lower legs in September 2015. The RO had granted service connection for cluster headaches and assigned a 10 percent rating, effective October 1, 1997, and a 50 percent rating from September 28, 2015. In January 2016, the Veteran reported for a VA central nervous system examination. A VA physician reviewed the claims file; considered the Veteran's accounts; and discussed the Veteran's medical history (to include cluster-type headaches, a high cervical vascular anomaly, and subsequent right suboccipital craniotomy with clipping of subarachnoid arteriovenous fistula). This physician indicated this residual of an aneurysm that required brain surgery is less likely than not proximately due to or the result of the Veteran's service-connected cluster-type headaches. However, the physician opined that patients with cluster-type headaches have potential secondary causes such as a structural brain lesion. The physician suggested further imaging studies to confirm this hypothesis. Nevertheless, when performed, the studies were wholly normal. In January 2016, the Veteran also reported for a VA peripheral nerve conditions examination. After review of the Veteran's medical history, the Veteran's lay accounts, and instant evaluation findings, this clinician opined that there were was no objective evidence of current lower extremity sensorimotor deficits. The clinician indicated that additional testing was necessary to clarify the Veteran's report of paresthesias. In February 2016, the clinician indicated nerve conduction studies of the Veteran's lower extremities revealed electrodiagnostic evidence of moderately severe lower extremity distal polyneuropathy. The clinician indicated that this was "most likely" secondary to hypothyroidism. As such, the clinician indicated that the Veteran's current moderately severe lower extremity distal polyneuropathy is less likely than not proximately due to or the result of the Veteran's service-connected cluster-type headaches. In her February 2016 notice of disagreement (NOD), the Veteran noted that he received treatment for cluster headaches. The Veteran also indicated that she underwent brain surgery to repair the effects two aneurysms. The Veteran wrote that he believed that his headaches and peripheral neuropathy are symptoms "secondary to" his brain aneurysms. At the December 2019 Board hearing, the Veteran conveyed that he underwent surgery after retirement. The Veteran also testified that after his separation from active-duty service he kept having "headaches, headaches, headaches, headaches." See December 5, 2019 Hearing Transcript, p. 3. In January 2020, the Veteran submitted a private physician's statement (Dr. B.). Dr. B. wrote that the Veteran's paralysis resulted from an extremely rare type of cerebrovascular fistulaconsequential to headaches. Dr. B. opined that blast injuries and falls carrying heavy equipment during active-duty service in 1993-1997 at Fort Sill caused the Veteran's disorder. The physician provided neither clinical evidence nor rationale based upon medical to support his etiological opinion. In June 2021 a VA physician provided an addendum, responsive to the Board's April 2021 remand directives. The physician reviewed the lay and medical evidence and provided comprehensive opinions. The physician opined that it is less likely than not that Veteran's residuals for arteriovenous (AV) fistula repair/brain surgery were incurred in, aggravated by, or otherwise attributable to, any incidence of service. As a rationale for this negative nexus opinion the physician articulated that, [L]imited documentation is available as to the initial diagnosis and surgical treatment of [the] Veteran's cerebrovascular condition. [...] Dr. [...] B. notates a diagnosis of cerebrovascular dural arteriovenous fistula and references prior exposures to blast injuries, falls, and heavy lifting while in service in the 1990s. Though an opinion of direct [service connection] and aggravation is checked in [...] B.'s statement, a medical rationale and/or references are not provided to support these contentions. 'Dural atriovenous fistulas (dAVFs) are abnormal connections between an artery and a vein in the tough covering over the brain or spinal (dura mater) . . . Most dural arteriovenous fistulas have a clear origin, although some result from identifiable causes such as traumatic head injury, infection, previous brain surgery or tumors. Most authorities think that dAVFs involving the larger brain veins usually arise from progressive narrowing or blockage of one of the brain's venous sinuses, which route circulated blood from the brain back to the heart.' In this case, there is no medical documentation of TBI [traumatic brain injury] or brain tumors/surgery/infection during active service that would or could have contributed to the Veteran's subsequent of dAVF. Headaches (including cluster /migraine/tension type which are diagnosed in service) are NOT in and of themselves causally associated with the development of dAVFs. Though headache may be a presenting symptom of hemorrhage or obstruction from a dAVF, there is no data to support or suggest that dAVFs (which are structural/anatomical abnormalities within the head) would or could be worsened or aggravated by a chronic headache condition that is not itself associated with an underlying neurological structural cause or lesion. Up until the Veteran's reportedly abrupt onset of an acute headache and quadriplegia in 2013, he had no significant neurologic deficits/lesions noted on previous exams or on diagnostic testing and imaging studies to suggest that his chronic headaches were secondary to any underlying cause [...] There is therefore no evidence to support that the Veteran's chronic SC headaches had any link/nexus to the acute headache with quadriplegia found to be due to dAVF in 2013. Moreover, this physician opined that it is less likely than not that the Veteran's residuals for AV fistula repair/brain surgery were proximately caused by, or aggravated by, his SC cluster-type headaches. As a rationale as to secondary service connection, the physician reported that medical literature provides no viable data to support that chronic headache conditions contribute, cause, or aggravate the structural abnormality between arteries and veins in the brain that forms dAVFs. Also, the physician underscored that the location of the dAVF in the posterior occipital region of the head is anatomically separate from the location of cluster-type headaches. As to the contention concerning polyneuropathy of the bilateral extremities, the physician provided negative nexus opinions as to both direct and secondary service connection. Here, the clinician provided a rationale for the former, noting that the Veteran's STRs provide no objective evidence of neuropathic symptoms to the lower extremity during active-duty services. Moreover, polyneuropathy first occurred in 2016, twenty years after service. As to the latter, the physician provided the following, The likely etiology of [the] Veteran's bilateral LE [lower extremity] polyneuropathy is clinically documented [...] as due to his thyroid disease. Medical literature establishes that polyneuropathy can result from a variety if cause [...] Chronic headache conditions are NOT causally associated with the development or progression [of such]. In September 2021, the Veteran's representative submitted a brief. In pertinent part, the representative recapitulated the Veteran's contentions and the contents of the medical evidence of record. The Veteran believes that that residuals of an aneurysm that required brain surgery, polyneuropathy of the right lower extremity, and polyneuropathy of the left lower extremity were proximately caused by, or aggravated beyond their natural progressions by, service-connected cluster-type headaches. The Board has considered the Veteran's sincere belief; however, upon review of the evidence of record, the Veteran does not have the specialized medical knowledge to render an opinion as to proximate cause or aggravation of these disabilities. Jandreau, 492 F. 3d 1372; Kahana, 24 Vet. App. 428. While Dr. B. reported that blast injuries and falls carrying heavy equipment during active-duty service caused the Veteran's disorder (presumably disabilities). This clinician provided neither clinical evidence nor rationale based upon medical to support his etiological opinion. As such, the Board assigns highly diminished probative weight to this unsupported opinion. See Sklar v. Brown, 5 Vet. App, 140 (2003). In contrast, the Board assigns significant probative weight to the robust opinions of the June 2021 VA physician. As articulated above, this physician assessed evidence and referred to specialized medical knowledge to formulate opinions which addressed all theories of entitlement which the Veteran contended. Moreover, this physician supported every aspect of the opinion with substantial rationales. While the present disability requirements exist for residuals of an aneurysm post brain surgery; polyneuropathy of the right lower extremity; and polyneuropathy of the left lower extremity. As discussed above, the most competent clinical evidence of record fails to disclose that there were any incurrences of these disabilities during active-duty service. Without in-service incurrences, there can be no nexuses drawn. Consequently, the possibility of granting service connection for these three disabilities on a direct basis is not possible. Saunders, 886 F. 3d 1356 Moreover, the weight of evidence fails to establish that these three current disabilities were proximately caused by, or aggravated beyond their natural progressions by, the Veteran's service-connected allergic rhinitis. Consequently, service connection is not possible for these disabilities on a secondary basis. Allen, 7 Vet. App. 439. Therefore, the weight of competent and credible evidence is against granting the Veteran's three service connection claim and there are no doubts to be resolved. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.