Citation Nr: 21070248 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 15-35 330 DATE: November 23, 2021 ORDER Service connection for residuals of a cerebrovascular accident (CVA), claimed as secondary to service-connected post-traumatic stress disorder (PTSD), is denied. FINDING OF FACT It is less likely than not (less than 50 percent probability) that the Veteran's CVA is either directly related to his active military service, or is proximately due to or the result of his service-connected PTSD and his medication taken to treat his PTSD, or that was aggravated by his service-connected PTSD and his medication taken to treat his PTSD. CONCLUSION OF LAW The criteria for service connection for residuals of a CVA, claimed as secondary to service-connected post-traumatic stress disorder (PTSD), have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty for training (ACDUTRA) in the U.S. Army National Guard from October 1979 to February 1980. He also served on active duty from November 1990 to September 1991, and January 2003 to November 2004. The matter is on appeal before the Board from a May 2014 rating decision. The Board notes that the Veteran initially requested a hearing before a Veteran's Law Judge in connection with his appeal. However, he was a "no show" for the scheduled hearing, and neither provided good cause for his failure to appear, nor requested rescheduling. The hearing request is therefore considered withdrawn. 38 C.F.R. § 20.704. The Board previously remanded the issue for further development in December 2019, September 2020, and May 2021. The development is completed, and the issue is again before the Board for readjudication. Service Connection CVA Residuals The Veteran asserts that service connection for a CVA is warranted. Specifically, he contends that it is his belief that the CVA, claimed as a stroke, was caused by his service-connected PTSD, to include as a result of the medications prescribed treat his PTSD. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). A review of the Veteran's service treatment records (STRs) does not show any diagnoses, treatments, or complaints that may be related to a CVA. The Veteran's private and VA treatment records reflect that the Veteran suffered a CVA in August 2011. He underwent a VA examination in December 2019, at which time it was noted that the Veteran had experienced a CVA in 2011. The examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was incurred in or caused by his military service. The examiner stated that there were no medical records showing a diagnosis of, or treatment for, the CVA or any related cerebrovascular condition while the Veteran was still in service. The examiner also opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was proximately due to or the result of the Veteran's service-connected PTSD, including any medication taken to treat his PTSD. The examiner explained that a CVA/transient ischemic attack, commonly has multiple contributing factors and causes, as it is commonly idiopathic, or multifactorial in nature, including heart attack, metabolic syndrome, trauma, illicit drug use, infections, arrhythmia, and/or diet. The examiner stated there is no direct pathophysiologic link between PTSD, or the treatment of PTSD, causing a CVA/transient ischemic attack. In addition, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was aggravated by his service-connected PTSD, including any medication taken to treat his PTSD. The examiner reiterated that CVA/transient ischemic attack, commonly has multiple contributing factors and causes, as it is commonly idiopathic, or multifactorial in nature, including heart attack, metabolic syndrome, trauma, illicit drug use, infections, arrhythmia, and/or diet. The examiner noted there is no direct pathophysiologic link between PTSD or the treatment of PTSD causing or aggravating CVA/transient ischemic attack. Addendum VA medical opinions were obtained in March 2021. The VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was incurred in or caused by his active military service. The examiner noted that the Report of Medical History and examination on July 10, 1998, did not reveal history or physical examination findings for ongoing acute or chronic treatment of a CVA condition. The examiner indicated that the December 2019 VA examination documented a diagnosis of CVA. The examiner reported that a review of the Veteran's medical record did not reveal continuous ongoing medical treatment or aggravation of either an acute or chronic CVA condition during the time of his discharge from active military service to present day. The examiner also opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA is proximately due to or the result of the Veteran's service-connected PTSD, including any medication taken to treat his PTSD. Then, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was aggravated by his service-connected PTSD, including any medication taken to treat his PTSD. For both opinions, the examiner reiterated that the Report of Medical History and examination on July 10, 1998, did not reveal history or physical examination findings for ongoing acute or chronic treatment of a CVA condition. Also, the December 2019 VA examination documented a diagnosis of CVA. The examiner explained that there are two main causes of stroke: a blocked artery (ischemic stroke) or leaking or bursting of a blood vessel (hemorrhagic stroke). Some people may have only a temporary disruption of blood flow to the brain, known as a transient ischemic attack (TIA), which doesn't cause lasting symptoms. A review of the Veteran's medical record was negative for any PTSD medications that have a side effect profile causing cerebrovascular accident. Additional VA addendum medical opinions were obtained in July and September 2021. In the July 2021 VA addendum opinion, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was aggravated by his service-connected PTSD, including any medication taken to treat his PTSD. The examiner noted that the Veteran has been taking sertraline (Zoloft) to manage his PTSD. The examiner explained that sertraline is an SSRI, which inhibits the reabsorption of serotonin, and leaves the Veteran unable to form clots, which will lead to excessive bleeding. However, this was not the case for the Veteran. The Veteran suffered a CVA due to cerebral artery occlusion, which means a clot formed in an artery and blocked the blood flow. Thus, there is no pathophysiological nexus to the Veteran's CVA due to cerebral artery occlusion to his PTSD or medications used to manage his PTSD. In the September 2021 VA addendum medical opinions, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA is proximately due to or the result of the Veteran's service-connected PTSD, including any medication taken to treat his PTSD. The examiner noted that the Veteran suffered a left posterior circulation stroke in August 2011. Imaging showed occlusion of the left vertebral artery. The examiner explained that prior to this, the Veteran's records do not show that he was on any medications for SSRI. In addition, the medications for the Veteran's PTSD of sertraline and trazodone, which were started after his stroke, are not expected, or known to cause the atherosclerotic process that blocked off the left vertebral artery and resulted in stroke. Furthermore, the Veteran's primary care provider and VA medical records just prior to the stroke show that the Veteran had multiple risk factors that are medically accepted to be stroke risk factors. A primary care provider note from January 12, 2011 documents the Veteran with Type 2 diabetes, hyperlipidemia, obesity, and hypertension (none of which allergic rhinitis service connected conditions). The examiner stated that PTSD is a psychiatric disease and has no direct pathophysiological connection to the atherosclerotic process that blocked off the Veteran's left vertebral artery and resulted in stroke. The examiner also opined that it was less likely than not (less than 50 percent probability) that the Veteran's CVA was aggravated beyond its natural progression by his service-connected PTSD, including any medication taken to treat his PTSD. The examiner explained that CVA is an event. For the Veteran, this occurred in Aug 2011. Ischemic left posterior circulation CVA (which is what occurred in the Veteran) led to the death of brain tissue. This is noted on the December 3, 2011 MRI showing "encephalomalacia," which is a term that means that portion of the brain has died as a result of liquefactive necrosis. After this event, the Veteran's medical records do not show that he had another ischemic CVA. Hence, it is incorrect to presume that an ischemic CVA can in any way be "aggravated." A portion of the brain tissue is dead because of the August 2011 CVA and cannot be aggravated beyond this. An August 28, 2011 MRA, at the time of the CVA, already shows "no flow" in the left vertebral artery and cannot be aggravated beyond this. Irrespective to this, PTSD and the medications taken for PTSD, trazodone and sertraline, do not play a role in ischemic stroke pathogenesis. The Veteran's other medical conditions prior to the CVA, including diabetes mellitus type II, hyperlipidemia, obesity, and hypertension (none of which are service connected conditions), are the primary and accepted risk factors for the pathogenesis of stroke. Thus, it is less likely than not the Veteran's CVA was aggravated by his PTSD, including his medications taken for PTSD, because CVA is considered an event unable to be aggravated. Further review of the Veteran's private and VA treatment records does not provide any findings of any greater significance than the findings in the above VA medical opinions. That is, the Veteran's VA and private treatment records do not provide any objective medical evidence linking the Veteran's CVA either directly to his military service, or to his service-connected PTSD and his medications to treat his PTSD. Consideration is given to the Veteran's contentions that his claimed CVA condition was either incurred in or caused by his military service, or is secondary to his service-connected PTSD disability, to include his PTSD medications. While lay persons are competent to provide opinions pertaining to certain medical issues, the etiology of a CVA, as is specific to this case, is outside the realm of common knowledge for someone, such as the Veteran, who does not possess medical training, specialized expertise, or experience. Jandreau v. Nicholson, 492. F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, no probative value shall be assigned to the Veteran's belief that his CVA is related to his service-connected PTSD and his medications to treat his PTSD. Based upon the foregoing, service connection for residuals of a CVA is not warranted. The totality of the VA medical opinions provide that it is less likely than not (less than 50 percent probability) that the Veteran's CVA is either directly related to his military service, or is proximately due to or the result of the Veteran's service-connected PTSD and the medications to treat his PTSD, or is aggravated by his service-connected PTSD and the medications to treat his PTSD. The Board notes that the December 2019 and March 2021 VA medical opinions had been noted to be inadequate in the September 2020 and May 2021 Board decisions because the rationale's when viewed on their own still left some questions unanswered. However, with the additional opinions rendered in July and September 2021, and when all the opinions are taken in conjunction, a thorough and well rationalized opinion is proffered, which provides probative value. In addition, the record does not reflect any objective medical opinions, and the Veteran has not submitted any objective medical opinions, linking his CVA to either his active military service or to his service-connected PTSD and his medications to treat his PTSD. As such, service connection for residuals of a CVA is not warranted, and the claim is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Lutgens-Staley, 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.