Citation Nr: A21019094 Decision Date: 12/01/21 Archive Date: 11/30/21 DOCKET NO. 181203-1413 DATE: December 1, 2021 REMANDED Service connection for amyloid angiopathy, also claimed as a left front hematoma, is remanded. Compensation under 38 U.S.C. § 1151 for amyloid angiopathy, also claimed as a left front hematoma, is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Army from July 180 to January 1986. A rating decision was issued under the legacy system in December 2017. In May 2018, the Veteran opted into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a Rapid Appeals Modernization Program (RAMP) election form and selecting the higher-level review (HLR) lane. The agency of original jurisdiction (AOJ), having determined that additional development was warranted, issued a RAMP supplemental decision in November 2018, which is the decision on appeal. In the December 2018 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. Therefore, the Board may only consider the evidence of record at the time of the RAMP supplemental claim decision on appeal, as well as any evidence submitted by the Veteran and his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). . Amyloid angiopathy The Veteran has been diagnosed with amyloid angiopathy, which is a vascular amyloidosis affected small and medium-sized arteries of the leptomeninges and cerebral cortex, resulting in microinfarcts or in hemorrhage. See Dorland's Illustrated Medical Dictionary 87 (31st ed. 2007). He has a history of headaches in 2009, a left frontal lobe bleed in 2011, and a grand mal seizure in 2014. The Veteran is service-connected for a variety of orthopedic or musculoskeletal disabilities. He treated the pain from these disabilities with ibuprofen and aspirin. Private treatment records from November 2015 show that the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, were contraindicated in the Veteran due to his risk of intracranial hemorrhage or bleeding. He contends that his amyloid angiopathy was caused or aggravated by the medications used to treat his service-connected disabilities. Regarding causation, private treatment records from August 2014 show the Veteran underwent genetic testing which came back positive for APO-e4 homozygosity. Per the records, patients with this status are more likely to have an inflammatory form of amyloid angiopathy with hemorrhage, just as the Veteran presented. Additional records from October 2014 stated that, from an intracranial hemorrhage standpoint, there was no other underlying etiology. The private treatment provider determined that the cause of the Veteran's amyloid angiopathy was genetic, but also acknowledged that aspirin and NSAIDs increased his risk of an intracranial hemorrhage. Therefore, the pertinent question is whether his use of those drugs aggravated his amyloid angiopathy beyond its normal progression. An October 2018 VA opinion acknowledged the genetic etiology of the Veteran's condition but did not adequately address whether his medication use aggravated that condition. The examiner stated that they were not medically related, and that the medical literature did not support such a relationship. However, he did not address the November 2015 private treatment records, or the medical literature submitted by the Veteran in January 2018 which noted that the use of antiplatelet agents following an intracranial hemorrhage can increase the risk of a recurrence. This represents a failure in VA's pre-decisional duty to assist, and corrective action is warranted. Notably, the Veteran also asserted that his amyloid angiopathy is directly related to service. However, the Board does not find that any additional development is warranted to address that theory of entitlement. Compensation under 38 U.S.C. § 1151 for amyloid angiopathy A veteran who becomes disabled due to VA medical treatment may receive compensation for a qualifying additional disability in the same manner as if such additional disability were service-connected. An additional disability is a qualifying disability if: (1) it was not the result of the veteran's willful misconduct; (2) the disability was caused by VA hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the VA; and, (3) the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination, or the proximate cause of the disability was an event not reasonably foreseeable. 38 U.S.C. § 1151(a). The Veteran also asserts that VA did not provide adequate care when he presented for treatment for what was later diagnosed as amyloid angiopathy. This includes failing to correctly diagnose his disability. In an October 2018 opinion, a VA examiner stated that it was less likely than not that the Veteran's amyloid angiopathy was caused or worsened by VA's treatment. He stated that cerebral amyloid angiopathy is a very rare hereditary condition that is not routinely tested for. He also stated that, even if a diagnosis had been made earlier, there is no curative treatment, only supportive therapies. Therefore, there was no additional disability which resulted from an event that could have been reasonably foreseen by a reasonable healthcare provider and there was no failure by VA to timely diagnose or treat the condition. The Board does not find this opinion to be adequate. First, while the examiner states that an earlier diagnosis would not have mattered because there are no cures for amyloid angiopathy, he failed to address whether an earlier diagnosis would have resulted in the Veteran being taken off aspirin and NSAIDs sooner, as these medications can increase his risk of a brain hemorrhage. Second, the examiner states that "there was no additional disability..." However, the Veteran sustained a left frontal lobe bleed in 2011 and a grand mal seizure in 2014. The inadequacy of this opinion represents a failure of VA's pre-decisional duty to assist, and corrective action is warranted. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's amyloid angiopathy was at least as likely as not aggravated beyond its natural progression by ibuprofen and aspirin used to treat his service-connected disabilities. The examiner should consider the medical treatise evidence submitted by the Veteran ("Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy") in January 2018, as well as the November 2015 private treatment records showing that the use of aspirin and ibuprofen was contraindicated for the Veteran. The examiner should also address a) whether the Veteran sustained any additional disability, including a left frontal lobe bleed in 2011 and a grand mal seizure in 2014, associated with his use of ibuprofen and aspirin, b) whether such disability was reasonably foreseeable by VA healthcare providers who treated him prior to those incidents, and c) whether such disability was due to the carelessness, negligence, lack of proper skill, error in judgment or a similar instance of fault by VA providers. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shamil Patel, 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.