Citation Nr: 21029273 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 17-37 300 DATE: May 13, 2021 ORDER Entitlement to service connection for a lacunar infarct/stroke is denied. FINDING OF FACT The Veteran's lacunar infarct/stroke did not have its onset during his active service and is not otherwise etiologically related to such service, to include herbicide exposure sustained during such service; and, was not caused by, proximately due to, or chronically worsened by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for lacunar infarct/stroke are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from July 1968 to April 1970, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In connection with this appeal the Veteran testified at a hearing before the undersigned Veterans Law Judge in July 2020. A transcript of that hearing has been added to the record. This case was previously before the Board, most recently in October 2020. At that time, the issue currently on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection Lacunar Infarct/Stroke The Veteran has asserted that his lacunar infarct/stroke was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD), or in the alternative, was the result of herbicide exposure sustained while serving in the Republic of Vietnam. Specifically, the Veteran reported that he had significant symptoms of anxiety, stress, depression, and panic attacks that he believed contributed to his 2001 lacunar infarct/stroke, and that he had a history of running and leading an active lifestyle. Service treatment records are silent for complaints of, treatment for, or a diagnosis of a lacunar infarct/stroke while the Veteran was in active service, to include any symptoms which could ultimately be attributed to a later diagnosis of such. In April 1970, the Veteran was afforded a separation examination. At that time, the Veteran denied any symptoms which could be later attributed to his lacunar infarct/stroke, and his vascular system was noted to be clinically normal upon physical examination. Post-service medical evidence of record show that the Veteran was first shown to have diagnostic imaging that revealed the presence of a right frontal lacunar infarct in 2001. There is no indication from the post-service medical records that the Veteran's lacunar infarct was in any way related to his active service. In May 2019, the Veteran was afforded a VA examination. At that time, the Veteran reported that in the 1960's, he experienced a severe head injury with brief loss of consciousness, and clear liquid running from his nose for approximately four hours. He further reported that he had PTSD and depression, that he believed resulted in his lacunar infarct/stroke. The examiner noted a January 2001 magnetic resonance imaging scan (MRI) report which revealed a small punctate lacunar infarct within the right frontal white matter. Subsequent brain MRI in September 2010 was noted to reveal dilated ventricular with normal pressure hydrocephalus. The examiner diagnosed lacunar infarct by history. The examiner opined that the Veteran's disability was less likely as not incurred in or caused by the claimed in-service injury, event, or illness, to include herbicide exposure sustained while serving in the Republic of Vietnam. In so finding, the examiner noted that there was no documented evidence that the onset of the Veteran's lacunar infarct was during his active service. The examiner explained that a lacunar infarct/stroke is a small vessel disease that was caused by blood flow blockage in the small vessel arteries. The examiner noted that the risk factors associated with a lacunar infarct were hypertension, heart disease, carotid artery disease, and hyperlipidemia. The examiner noted that a review of the record showed that the Veteran was diagnosed with hypertension and started on medication for control in 2001. The examiner noted that the Veteran's age, hypertension, and sedentary lifestyle may have strongly contributed to him having an ischemic stroke. The Veteran was afforded another VA examination in December 2020 to determine the nature and etiology of his lacunar infarct/stroke. After a review of the record, the VA examiner opined that the Veteran's lacunar infarct/stroke was less likely as not to have been incurred in or caused by pain during active service. In so finding, the VA examiner noted that the occlusion of a small, single, penetrating artery/arteries was the cause of the Veteran's lacunar infarct. The examiner noted that the leading causes of such were hypertension, smoking, and diabetes; and in a smaller percentage of patients, were the result of carotid artery/arteries or cardiac/heart microembolism. The examiner noted that the Veteran's service records were silent for any signs or symptoms that would indicate a lacunar infarct during service, and his lacunar infarct was likely the result of his hypertension and life-long smoking habit. The examiner also opined that it was less likely as not that the Veteran's lacunar infarct/stroke was caused or aggravated by his service-connected PTSD or MDD. In so finding, the VA examiner noted that there was no medical association between PTSD/MDD and lacunar infarct, and as noted, the leading causes of such were hypertension, smoking, and diabetes. The examiner noted that there was zero association with PTSD, depression, or any other mental illness. An addendum VA medical opinion was obtained in January 2021. At that time, the VA examiner opined that it was less likely as not that the Veteran's lacunar infarct/stroke was related to his PTSD/MDD. In so finding, the examiner noted that the disabilities were separate and distinct medical conditions, and one did not cause or have an effect on the other. Specifically, the examiner noted that PTSD was a mental health condition that was caused by traumatic stressor, while lacunar infarct/stroke was due to an occlusion or infarct of arteries to the brain caused by hypertension, smoking, and diabetes. As such, the examiner noted that a nexus between the two could not be established. Further, the examiner opined that the Veteran's lacunar infarct/stroke was less likely as not related to his active service, to include herbicide exposure. In so finding, the VA examiner noted that the Veteran's service records were silent for any diagnosis or symptomatology of a lacunar infarct/stroke, and lacunar infarct/strokes were not a disability presumed to be the result of exposure to herbicides. As such, there was no cause and effect to herbicide exposure, and a nexus could not be established. An additional addendum VA medical opinion was obtained in February 2021. At that time, the VA examiner opined that it was less likely as not that the Veteran's lacunar infarct/stroke was caused or aggravated by the Veteran's service-connected PTSD with MDD. In so finding, the examiner noted that according to current medical literature, strokes were classified into two subtypes, brain ischemia die to thrombosis, embolism, or systemic hyperfusion; and brain hemorrhage due to intracerebral hemorrhage or subarachnoid hemorrhage. The examiner explained that a stroke is the acute neurologic injury that occurs as a result of one of those pathologic processes. The examiner noted that approximately 80 percent of strokes were due to ischemic cerebral infarction, and 20 percent were due to brain hemorrhage. It was noted that an infarcted brain was pale initially, and within hours to days, the gray matter became congested with engorged, dilated blood vessels and minute petechial hemorrhages. The examiner noted that when an embolus blocking a major vessel migrates, lyses, or disperses within minutes to days, recirculation into the infarcted area can cause hemorrhagic infarction and may aggravate edema formation due to disruption of the blood-brain barrier. A primary intracerebral hemorrhage was noted to damage the brain directly at the site of the hemorrhage by compressing the surrounding tissue. The examiner noted that physicians must initially consider whether a patient with suspected cerebrovascular disease was experiencing signs or symptoms suggestive of ischemia or of hemorrhage. The examiner noted that the great majority of ischemic strokes were caused by a diminished supply of arterial blood, which carries sugar and oxygen to brain tissue. Another cause of stroke was noted to be difficult to classify, was a stroke due to occlusion of veins that drained the brain of blood. Venous occlusion was noted to cause brain edema, and could also cause both brain ischemia and hemorrhage into the brain. The examiner noted that there were three main types of brain ischemia, thrombosis, generally referring to local in situ obstruction of an artery which could be due to disease of the arterial wall, such as arteriosclerosis, dissection, of fibromuscular dysplasia; embolism, referring to particles of debris originating elsewhere that block arterial access to a particular brain region; and, systemic hypoperfusion, which is a more general circulatory problem, manifesting itself in the brain and perhaps other organs. The examiner also noted that blood disorders are an uncommon primary cause of stroke, but that increased blood coagulability could result in thrombus formation and subsequent cerebral embolism in the presence of endothelial lesion located in the heart, aorta, or large arteries that supply the brain. As such, the examiner concluded that while the cause of a stroke was multifactorial, they were not caused or aggravated by psychiatric conditions such as depression, anxiety, or trauma related disorders. The Board finds that the May 2019, December 2020, January 2021, and February 2021 medical VA medicals opinion are adequate, especially when read on conjunction with one another. In this regard, the examiners thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, and provided a supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, there is no medical opinion of record to the contrary. As such, the VA medical opinions of record are the most probative evidence of record. While the laypersons are competent to report observable symptoms, the Veteran is not competent to provide a medical opinion linking his lacunar infarct/stroke to his active service, or an opinion that such disability was caused or aggravated by a service-connected disability. Opinion of that nature would require medical knowledge, training, and expertise that is simply outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion in this case. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a lacunar infarct/stroke is not warranted. 38 U.S.C. § 5107 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Andrew Ledman II 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.