Citation Nr: 21039950 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-54 260 DATE: July 1, 2021 ORDER Entitlement to service connection for brain thrombosis, to include as secondary to service-connected migraine headaches is denied. Entitlement to service-connection for left upper extremity paralysis, to include as secondary to coronary artery disease (CAD) and brain thrombosis is denied. Entitlement to service connection for left lower extremity paralysis, to include as secondary to CAD or brain thrombosis is denied. FINDINGS OF FACT 1. The Veteran's brain thrombosis is not directly related to his military service or secondary to his service-connected migraine headaches. 2. The Veteran's left upper extremity paralysis is not related to his military service; the Veteran is not service-connected for brain thrombosis or CAD. 3. The Veteran's left lower extremity paralysis is not related to his military service; the Veteran is not service-connected for brain thrombosis or CAD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for brain thrombosis, to include as secondary to service-connected migraine headaches have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for entitlement to service-connection for left upper extremity paralysis, to include as secondary to CAD and brain thrombosis have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 3. The criteria for entitlement to service connection for left lower extremity paralysis, to include as secondary to CAD or brain thrombosis have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the United States Air Force from November 1998 to March 2000. This matter comes to the Board of Veterans' Appeals (Board) on appeal from August 2015 and September 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues on appeal in November 2018 for further development. All necessary development has been completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection 1. Entitlement to service connection for brain thrombosis, to include as secondary to service-connected migraine headaches. 2. Entitlement to service-connection for left upper extremity paralysis, to include as secondary to CAD and brain thrombosis. 3. Entitlement to service connection for left lower extremity paralysis, to include as secondary to CAD or brain thrombosis. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). The Court has established that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, that list includes organic disease of the nervous system and brain thrombosis. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic disease of the nervous system and brain thrombosis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307. Secondary service connection is also warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran is seeking service connection for brain thrombosis and paralysis of the left lower and left upper extremities. The Veteran claims that his brain thrombosis is related to his military service and secondary to his service-connected migraine headaches. He also claims that his paralysis of the left upper and left lower extremities is related to his CAD and/or brain thrombosis. See September 2015 NOD and June 2016 VA Form 21-526(b), Veteran Supplemental Claim. Service treatment records are silent for any signs, symptoms, diagnosis, complaints or treatment of brain thrombosis, paralysis of the left lower extremity, and/or paralysis of the left upper extremity. However, the Veteran's service treatment records do show complaints and diagnosis of migraine headaches. Private treatment records show that in November 2007, the Veteran had an acute right middle cerebral artery stroke with resultant left-sided hemiparesis. An impression noted evidence of dissection and occlusion of the right internal carotid artery (etiology uncertain). Also, an impression noted a 10 plus year history of migraine headachesin the past associated on one occasion with transient left sided weakness. In August 2016, the Veteran was afforded a VA examination for central nervous system and neuromuscular disease. The Veteran was diagnosed with thrombosis, transient ischemic attack (ITA), or cerebral infarction with a date of November 2007. The VA examiner opined that the Veteran sustained an acute cerebrovascular accident/stroke involving the right middle cerebral artery distribution. Residual left-sided hemiplegia/hemiparesis was noted at that time. A review of the Veteran's private treatments records at the time of the stroke specifically documented that the stroke related to right internal carotid artery dissection specifically. A review of literature indicated that individuals with a long history of migraine headaches were at greater risk for stroke, especially with advancing age. Since the Veteran's stroke in 2007 was specifically related to right carotid artery dissection, it seemed less than 50 percent probable that the Veteran's stroke would be relatable to his service-connected migraine headaches directly. Therefore, the VA examiner opined that the Veteran's history of right middle cerebral artery distribution cerebral vascular accident with residual left-sided hemiplegia/hemiparesis (claimed as stroke) was not as likely as not proximately due to and/or the direct result of his service-connected migraine headaches. In December 2017, a VA medical opinion was obtained. The VA examiner opined that it was less likely than not that the Veteran's brain thrombosis was proximately due to or the result of the Veteran's service-connected condition. The examiner explained that the Veteran suffered an acute cerebral vascular accident in 2007 due to a right carotid artery dissection and thrombosis of the middle cerebral artery. The Veteran's carotid dissection was not caused by his migraine headaches. Thus, the residuals of the Veteran's cerebral vascular accident were not due to his migraines. In December 2019, another VA medical opinion was obtained. The examiner opined that the Veteran's brain thrombosis was less likely than not proximately due to or the result of the Veteran's service-connected migraine headaches. The Veteran's right internal carotid artery dissection caused the Veteran's middle cerebral artery infarction. The Veteran's service-connected migraine headache did not cause the Veteran's cerebral infarction. The Veteran did not have a recurrent cerebral infarction or carotid artery dissection, and his middle cerebral artery infarction with resultant left hemiparesis had stabilized/improved after the event. The current severity of the Veteran's condition was not greater than baseline. Since the Veteran's right internal carotid artery dissection with resultant middle cerebral artery infarction was not caused by nor aggravated by his service-connected migraine headaches, the question of left hemiparesis was moot. Finally, in November 2020, a VA medical opinion was rendered. The examiner opined that the Veteran's medical records did not support that that the Veteran's claimed brain thrombosis was at least as likely due to his military service. There was no evidence of a brain thrombosis or stroke during the Veteran's active duty service. He was discharged in March 2000 without any evidence of brain thrombosis or a stroke. He did not submit any pertinent records from his first year after discharge showing treatment for a brain thrombosis. The Veteran was admitted to the hospital in November 2007 with the sudden onset of left sided paralysis. The Veteran's November 12, 2007 computed tomography angiogram showed right basal ganglia infarction extending into the right frontal lobe with a right carotid artery dissection. The Veteran was diagnosed with a stroke due to the carotid artery dissection with cerebral infarction. He had residual left sided paresis/paralysis since the time of this event, but there was no evidence that the Veteran experienced a brain thrombosis during his active duty service. The November 2020 VA examiner also opined that the Veteran's left upper extremity paralysis and left lower extremity paralysis was due to his brain thrombosis. The examiner explained that the Veteran was admitted to the hospital in November 2007 with a sudden onset of left sided paralysis. His November 12, 2007 computed tomography angiogram showed right basal ganglia infarction extending into the right frontal lobe with a right carotid artery dissection. The Veteran was diagnosed as having a stroke due to the carotid artery dissection with cerebral infarction. The Veteran had extensive therapy after the stroke but did not have persistent spastic paralysis of the left upper extremity or the left lower extremity related to his stroke. The November 2020 VA examine further opined that it was less likely than not that the Veteran's brain thrombosis was due to his service-connected migraine headaches. The Veteran was admitted to the hospital in November 2007 with the sudden onset of left sided paralysis. In November 12, 2007, a computed tomography angiogram showed right basal ganglia infarction extending into the right frontal lobe with a right carotid artery dissection. He was diagnosed as having a stroke due to the carotid artery dissection with cerebral infarction; therefore, migraine headaches were not a cause of carotid artery dissection. Carotid artery dissection was due to a separation of the layers of the artery wall and was the most common cause of stroke in young adults. The condition could happen spontaneously or due to trauma. Spontaneous dissection could be related to connective tissue disorders. However, most cases of spontaneous dissection happened without a known cause. The examiner indicated that migraine headaches were not a known cause of carotid artery dissection, and migraines would not affect the connective tissue of the carotid artery wall. The examiner also opined that there was no evidence that the Veteran's brain thrombosis was aggravated beyond its natural progression by his service-connected migraine headaches. There was no evidence for progression of his condition. The Veteran had extensive therapy due to his stroke, but he also had residual paralysis of the left side of his body. This had not changed appreciably since the time of his treatment for his stroke. He had not had any further treatment, hospitalization, or diagnosis of worsening of his stroke residual. The examiner explained that he could not attribute any aggravation of the Veteran's brain thrombosis to migraine headaches. The August 2016, December 2017, December 2019, and November 2020 VA medical opinions considered together as a whole are adequate and greatly weigh against the Veteran's claims. The VA medical opinions considered the Veteran's medical history and provided a sufficient rationale for the conclusions reached regarding service connection on a direct or secondary basis. Therefore, the Board finds that service connection is not warranted for the Veteran's brain thrombosis or paralysis of the left upper extremity and left lower extremity. The Veteran's brain thrombosis is not directly related to his military service or secondary to his service-connected migraine headaches. The VA examiner gave adequate opinions regarding service connection on a direct and secondary basis to support this conclusion. Moreover, there is no indication of diagnosis of thrombosis until many years after discharge from service, with the condition not indicated in treatment records until 2007. Further, secondary service connection is not warranted for the Veteran's paralysis of the left upper extremity and paralysis of the left lower extremity. Secondary service connection may be warranted when the Veteran's service-connected disability caused or aggravated his non-service-connected disability. Here, the Veteran is not service-connected for coronary artery disease or brain thrombosis. The Board notes that service-connected for coronary artery disease has been previously denied. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish entitlement to service connection for a secondary condition as a matter of law. See 38 C.F.R. § 3.310(a), (b) (providing for service connection for a disability only where such disability is proximately due to, the result of, or aggravated by, a disease or injury that is already service-connected); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Therefore, secondary service connection is not warranted. Moreover, the Veteran's paralysis of the left lower extremity and left upper extremity is not directly related to his military service. There is no evidence that the Veteran was treated for such disabilities in service or had an incident in service that led to his paralysis. Additionally, the Veteran has not argued that his paralysis is related to his military service. Therefore, without an indication of a nexus, the Board does not find it is necessary to obtain a medical opinion regarding the nature and etiology of the Veteran's paralysis as directly related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In sum, the weight of the evidence therefore reflects that the claimed brain thrombosis and paralysis of the left extremities not manifest in service or for many years thereafter, there is no relationship between the claimed disabilities and service or a service-connected disability. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claims for service connection. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Thus, service connection is denied. G. E. Wilkerson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, 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.