Citation Nr: 21014856 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 15-28 148 DATE: March 15, 2021 ORDER Service connection for residuals of cerebral vascular accident (CVA), including as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran’s residuals of CVA are aggravated by her service-connected PTSD. CONCLUSION OF LAW The criteria for secondary service connection for residuals of CVA are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1977 to September 1980. These matters are on appeal of an October 2017 rating decision. In October 2018, a hearing was held before the undersigned. A transcript of the hearing is of record. The Board remanded the appeal for further development in April 2019. The Veteran contends that her current residuals of a July 2010 CVA were either caused or aggravated by her service-connected PTSD. Service connection will be granted if it is shown that the Veteran has a disability resulting from personal injury incurred in or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Diseases diagnosed after discharge may 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). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence of (1) a current chronic disability for which service connection is sought; (2) an already service-connected disability; and (3) that the disability for which service connection is sought was either (a) caused or (b) aggravated by the already service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, reasonable doubt will be resolved in each such issue in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). After review of the evidence, the Board concludes that the evidence shows the Veteran has currently diagnosed residuals of a CVA that an October 2020 VA examiner opined is at least as likely as not aggravated by her service-connected PTSD. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.310. The evidence of record does not show, nor does the Veteran contend that her current residuals of CVA had their onset in service or are otherwise directly related to her service or any incident therein. An October 2017 VA examiner found that, although the Veteran had a stroke in July 2010, her symptoms had resolved and there were no residual focal neurological findings. However, VA treatment records, including in September 2017 and September 2020, reflect ongoing residuals such as right-sided weakness and tingling sensations in the right hand. Additionally, on October 2020 VA examination, the examiner noted the Veteran’s current symptoms were bilateral upper and lower extremity weakness, short-term memory loss, and difficulty swallowing. In a November 2010 evaluation for the Social Security Administration, a VA clinician noted that the Veteran’s PTSD contributed to the severity of the Veteran’s symptoms and functional limitations. An October 2020 VA examiner found that the Veteran’s residuals of a CVA were not proximately due to or the result of her service-connected PTSD. The provided rationale was that PTSD is a psychological condition and vascular disease cannot be caused by a psychiatric illness. The clinician further opined that it is as likely as not that her service-connected PTSD aggravates her residuals of CVA because medical literature shows that PTSD is associated with an increased risk of stress and increased blood pressure and the influence of stress and a lack of sleep associated with PTSD exacerbates residuals of a CVA and prolongs the recovery time.   Accordingly, the Board finds that the weight of the evidence is against a finding that the Veteran’s CVA was caused by her service-connected PTSD. In this regard, the Board places great weight of probative value on the October 2020 opinion as it is based on review of the Veteran’s medical history and medical knowledge regarding whether a CVA could be caused by a psychological condition. The Board further finds that the evidence is at least in equipoise as to whether the Veteran’s service-connected PTSD aggravated her residuals of CVA. The Board places great weight of probative value on the October 2020 VA examiner’s opinion in this regard, as it is based on review of the Veteran’s medical history and knowledge of the interplay between a psychological condition and residuals of a CVA. Therefore, the Board resolves any reasonable doubt in favor of the Veteran and finds that entitlement to service connection for residuals of a CVA as secondary to PTSD is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Since the Board decision above grants service connection for residuals of CVA, consideration of the appeal seeking TDIU must be deferred, as entitlement to TDIU is inextricably intertwined with implementation of the Board’s decision granting service connection for residuals of CVA. Therefore, TDIU must be remanded.   The matter is REMANDED for the following action: After implementation of the award of service connection granted in the above decision, readjudicate the inextricably intertwined issue of entitlement to a TDIU. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. J. Wells-Green 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.