Citation Nr: 21073338 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-15 412 DATE: December 8, 2021 ORDER Entitlement to service connection for a neurological disorder, claimed as transient ischemic attack (TIA), to include as secondary to service-connected diabetes mellitus (DM) is denied. FINDING OF FACT The preponderance of the evidence is against finding that a neurological disorder, claimed as TIA, began during active service, or is otherwise related to an in-service event, injury, or disease, to include as due to service-connected DM. CONCLUSION OF LAW The criteria for service connection for a neurological disorder, claimed as transient ischemic attack (TIA), to include as secondary to service-connected diabetes mellitus have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309 REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from August 1966 to June 1967. In June 2020, the Board remanded the issue on appeal for further development, and the case has since been returned to the Board. The Board finds that the agency of original jurisdiction (AOJ) has substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. See 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Entitlement to service connection for a neurological disorder, claimed as TIA, to include as secondary to service-connected diabetes mellitus The Veteran claims that he suffers from TIAs or a history of TIAs and Alzheimer's disease as a result of his active-duty service. Alternatively, the Veteran contends that his conditions were caused or aggravated by his service-connected diabetes mellitus. The Veteran's service treatment records are silent for any complaints, treatment or diagnoses for cognitive or neurological disorders. However, the Veteran is service-connected for diabetes mellitus. Post-service treatment records reflect that the Veteran has undergone multiple MRIs and has experienced neurological symptoms and cognitive impairment. However, there are no definitive diagnoses in the Veteran's treatment records regarding TIAs or Alzheimer's disease/dementia. In an April 2014 treatment record, Dr. V. noted occasional spells of dizziness, slurred speech, and disorientation. Further he indicated an impression of spells of slurred speech and ataxia, cause unclear, "rule out TIA of posterior circulation." In August 2019, the Veteran submitted a private medical opinion which not only indicated that the Veteran suffered from TIAs, but that such were related to his diabetes mellitus and hypertension. Furthermore, the examiner found that the Veteran also suffered from Alzheimer's disease and that such was also due to his diabetes mellitus. However, the Board in its October 2019 remand, found that VA examinations and opinions were needed in order to clarify and render formal diagnoses. In November 2019 the Veteran underwent a VA Central Nervous System and Neuromuscular Disease examination with an accompanying disability benefits questionnaire (DBQ). The examiner found that the Veteran did not have any TIAs or cerebral vascular accidents (CVAs) in his medical records and that the Veteran was followed by a neurological clinic and there was no mention of any TIAs or complaints of focal weakness, speech or vision changes associated with a TIA. Furthermore, the examiner also noted that there was no TIA/stroke work up in the Veteran's records. The examiner noted that CTs were done in 2014 and 2019 and there was no evidence of any ischemic infarcts. The examiner also noted that there were no brain MRIs of record. The examiner did mention one episode of syncope in 2013 but found no recurrent episodes documented and no TIA diagnosis at the time. The examiner also found that the Veteran did not have any depression, cognitive impairment or dementia attributable to his claimed TIA and restless leg syndrome. The November 2019 examiner also provided an additional medical opinion. He found that the Veteran did not have a diagnosis of TIA "based on chart review so far." He further noted that it was less likely as not that the claimed TIA was caused or aggravated by the Veteran's service-connected diabetes mellitus and hypertension. The examiner noted that he reviewed the August 2019 private opinion which found that the Veteran had a history of TIAs, but the examiner found no mention of TIAs in the Veteran's medical record. He noted that no documentation or work up was completed during a claimed TIA, but that by its definition, a TIA is transient in nature. The examiner said that at the time of the November 2019 examination, the Veteran did not exhibit any signs or symptoms of a TIA. Nevertheless, in a June 2020 remand, the Board found the November 2019 examination and opinion were inadequate as the examiner failed to fully address the Board's October 2019 remand directives and an additional examination was ordered. This examination occurred in April 2021. The examiner opined that the Veteran's claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected DM. The rationale provided was: There is no pathology to render a dx. After careful extensive review of medical records, TIA has never been diagnosed. Neurology Dr. V., in 2014 did a very thorough evaluation for TIA, and both MRA and MRI of the head came back completely normal. Private letter from Dr. S. is not considered accurate, since he erroneously presumes a diagnosis of TIA, which has been clearly ruled out by the patients actual treating physicians. Further, the examiner opined that the Veterans claimed condition was less likely than not aggravated by the Veteran's service-connected DM. The rationale provided was: There is no pathology to render a dx. After careful extensive review of medical records, TIA has never been diagnosed. Neurology Dr. V., in 2014 did a very thorough evaluation for TIA, and both MRA and MRI of the head came back completely normal. Private letter from Dr. S. is not considered accurate, since he erroneously presumes a diagnosis of TIA, which has been clearly ruled out by the patients actual treating physicians. Finally, the examiner noted: There are no manifestations of claimed TIA. The rationale is that claimant has never been diagnosed with a TIA. Claimant states that his doctors have discussed a diagnosis of TIA with him, and that is true. Neurologist Dr. V in 2014, was very thorough in ruling out TIA as the cause of his sx. However, he just said that TIA needed to be ruled out, he did not ever officially diagnose a TIA. He very clearly said he was going to "rule out TIA". Which he did, an MRI and MRA of the head was done in 2014, and showed no signs of TIA. Furthermore, he has been seen by VA neurology from 2014-2020, and never has a TIA ever been diagnosed. I have reviewed, Dr. S's letter. As mentioned by previous VA examiner N.S, PhD, there are numerous problems with this letter. Primarily, Dr. S is not this patient physician. Dr. S has never been this patients physician. Dr. S erroneously diagnosed this veteran with TIA, or state that he has been diagnosed with a TIA, with no evidence to support this. Dr. S has never seen and evaluated this patient and has no medical evidence from his record to support that he has ever been diagnosed with a TIA. All of his rationales and opinions are based on this patient having a diagnosis of TIA, which is just not true or supported. The remaining evidence of record details continued complaints of a neurological disorder but no discussion on its etiology. Based on the foregoing evidence of record, the Board finds that service connection is not warranted. The Board finds the April 2021 VA opinion of record the most probative evidence of record as to the etiology of the Veteran's claimed neurological disorder because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. While the Board notes the positive August 2019 positive private opinion, it has been afforded less probative value. Indeed, as noted in the April 2021 opinion, this opinion was based on a diagnosis of TIA that is not supported by the evidence of record. The Board considered the Veteran's lay assertions as to the etiology of his claimed neurological disorder. Although the Veteran is competent to attest to his experiences, he is not competent in these circumstances to opine as to the etiology of his claimed neurological disorder. The Veteran has not been shown to have specialized medical knowledge that would be necessary to provide a competent opinion regarding service connection. The Board finds the April 2021 VA opinion of record to be more probative in this regard. The examiner considered the Veteran's history, and ultimately concluded that from a medical perspective, it is less likely that his claimed neurological disorder is related to service nor was it proximately due to or aggravated by his service-connected DM. In conclusion, the weight of the evidence is against the claim for service connection for a claimed neurological disorder. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. A. Elliott II, 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.