Citation Nr: 21024822 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 15-39 921 DATE: April 26, 2021 ORDER Entitlement to service connection for residuals of a transient ischemic attack (TIA), to include as secondary to service-connected sleep apnea and hypertension, is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran has residuals of TIA that are secondary to service-connected obstructive sleep apnea and/or hypertension, or that are otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for residuals of TIA are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1983 to March 2004. The Veteran testified at a hearing before the undersigned in February 2019. A transcript of the hearing has been associated with the claims file. The case was previously before the Board in June 2019 when it was remanded for additional development. The Board finds there has been substantial compliance with the remand directives for the claim decided herein.  Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for residuals of a TIA, to include as secondary to service-connected sleep apnea and hypertension. The Veteran contends that he has residuals of TIA and that his TIA is related to his service-connected sleep apnea and hypertension. 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 granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The questions for the Board are whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have current neurological residuals of a TIA and the Veteran’s TIA and any residuals were not due to or aggravated by his service-connected hypertension and obstructive sleep apnea. Service connection is not warranted. In July 2013 the Veteran reported that he had a TIA in August 2011 and the symptoms resolved within 6 hours. In April 2015, a private provider found that the Veteran’s stroke was most likely caused by or a result of the Veteran’s service-connected disabilities. The Veteran reported snoring history for over 20 years, and it was highly likely that he had obstructive sleep apnea for 20 plus years. The opinion provider concluded that since sleep apnea has been linked to hypertension and heart disease, it is likely the Veteran’s sleep apnea contributed to stroke and heart disease. At the hearing, the Veteran reported that he had not been treated for a stroke or related complaints before or during service. The Veteran testified that he suffered a TIA in the summer of 2011. He reported symptoms of drooping mouth, slurred speech, the inability to move one side of his face, and loss of motor skills. The Veteran said he was no longer being treated for the condition and that he had no residual major issues. In response to whether he had treatment after his TIA in 2011, the Veteran said an endarterectomy was done about three months after the TIA. The Veteran argued that his heart disease caused his stroke or made it worse. In March 2019 a private provider stated that the Veteran’s stroke was most likely caused by or a result of hypertension and obstructive sleep apnea. The provider noted that the National Stroke Foundation stated that sleep apnea can be an after effect of stroke but can also be the cause of a first time or recurrent stroke. Obstructive sleep apnea causes low oxygen levels and high blood pressure both of which can cause a future stroke. In a January 2020 VA opinion, the examiner concluded that it was “less likely than not” that the Veteran had any neurological residuals of a TIA or its treatment. The examiner detailed the history and records related to the August 2011 TIA and subsequent treatment and the March 2019 medical opinion. The VA examiner concluded that no neurological manifestations have persisted since the TIA, based on the clinical course and statements from the Veteran. The examiner identified the Veteran’s private treatment records, VA treatment records, and his statement that he has not had any further episodes of TIA and does not currently have any issues with loss of the major sensory or motor modalities, balance, coordination, swallowing, breathing, etc. or any difficulties with his abilities to do the activities of daily living. After concluding that the Veteran did not have any residuals related to the TIA, the examiner went on to address a possible relationship between the TIA and the Veteran’s service-connected hypertension or sleep apnea. The examiner concluded the TIA itself was not caused or aggravated by the Veteran’s service-connected disabilities. The examiner referenced medical literature and said the TIA was caused by carotid artery occlusive disease as confirmed by the imaging study of the carotid arteries. Carotid artery occlusive disease (a form of peripheral vascular disease) itself is caused by atherosclerosis which was related to the Veteran’s risk factors of hypertension, hyperlipidemia, sleep apnea, and cigarette consumption. The medical literature stated that the cigarette consumption would be the highest risk factor for carotid artery occlusive disease and thus, that would supersede the Veteran’s risk factors of the hypertension and the sleep apnea. The examiner comment on the private medical opinions and found that the medical literature and the actual cause for the Veteran’s stroke negates the opinion. Finally, the examiner reiterated that the Veteran does not have any neurological residuals due to his TIA. The examiner also provided a negative opinion as to whether any TIA residuals were aggravated by the service-connected hypertension or sleep apnea. The examiner reiterated that since there is no evidence of repetitive TIA/stroke episodes or need for surgical procedures, the Veteran’s neurological condition is stable. Since no deterioration has been shown in the Veteran’s neurological condition, then there can be no aggravation attributable to his hypertension or sleep apnea. The preponderance of the evidence is against a finding that the Veteran has neurological residuals of a TIA in August 2011. Entitlement to service connection is not warranted, on either a direct or secondary basis. The treatment records do not show residuals of the TIA in August 2011. Although the Veteran reported that he had neurological symptoms at the time of the TIA, he did not have continued treatment or major problems. The January 2020 VA examiner identified reviewed the complete record and offered a detailed rationale for concluding that that Veteran did not have any neurological residuals of his TIA. The opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Private opinions noted that the Veteran’s sleep apnea contributed to stroke and heart disease as well as that obstructive sleep apnea causes low oxygen levels and high blood pressure both of which can cause a future stroke. However, the January 2020 VA examiner discussed the Veteran’s medical history, risk factors, the medical literature, and the private medical opinions but concluded that the TIA itself was not due to or aggravated by his service-connected hypertension and obstructive sleep apnea. The VA examiner noted hypertension and sleep apnea are risk factors of carotid artery occlusive disease; however, the Veteran’s cigarette consumption was the highest risk factor and superseded the risk factors of hypertension and sleep apnea. The Board gives more probative weight to the VA examiner’s opinion because the examiner considered the medical record, the medical literature, and commented on the private opinions. Nieves-Rodriguez, 22 Vet. App. at 295. Although lay persons are competent to provide opinions on some medical issues, the diagnosis and etiology of a TIA or the presence of residuals is outside the realm of common knowledge of a lay person because it involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As the preponderance of the evidence is against the claim, entitlement to service connection for TIA, to include as secondary to service-connected sleep apnea and hypertension, is denied. M.E. LARKIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert J. Burriesci, 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.