Citation Nr: 21040427 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 14-40 547 DATE: July 3, 2021 ORDER Service connection for ischemic stroke is denied. FINDING OF FACT The weight of the evidence is against a finding that the Veteran's July 2010 cerebrovascular accident (CVA) is related to service or secondary to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for ischemic stroke have are not 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 September 1967 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision. The Veteran testified at a Board hearing in November 2016. In February 2019, the Board issued a decision denying the entitlement to service connection for ischemic stroke. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In December 2019, the Court granted a joint motion for remand, thereby vacating the Board's February 2019 decision and remanding the Veteran's claim back to the Board. More recently, in March 2020 and March 2021, the Board remanded for additional development. *** The Veteran seeks service connection for residuals of a July 2010 CVA, also described as an ischemic stroke. See 04/25/2011, Medical Treatment Record Government Facility, at 1. The Veteran asserts that his ischemic stroke is secondary to his service-connected coronary artery disease (CAD). The Veteran has submitted a favorable medical opinion from Dr. R.A.B. 12/19/2016, Correspondence; 04/26/2018, Medical Treatment Record - Non-Government Facility. Dr. R.A.B. has identified himself as the physician who did the Veteran's annual employment physicals prior to his stroke. Dr. R.A.B. opined that it is more likely than not that the Veteran's service-connected CAD caused his CVA. Dr. R.A.B.'s rationale was that, in a patient with CAD, the heart may not pump efficiently or may develop irregular rhythms either one of which may result in a blood clot or fragment of atherosclerotic plaque being pumped to the brain and causing a stroke. Dr. R.A.B. referenced literature indicating that CAD doubles a patient's risk for stroke. The Veteran has also submitted literature suggesting a relationship between PTSD and ischemic stroke. The Veteran is also service-connected for PTSD. In contrast, in April 2021, a VA examiner opined that it less likely than not that the Veteran's CVA is related to the Veteran's coronary artery disease, PTSD, or his presumed herbicide exposure. The examiner also opined that it is less likely than not that the Veteran's CVA residuals have been aggravated beyond its natural course due to "any cause, including CAD and psychological conditions." The April 2021 VA examiner explained that the current, widely accepted, peer-reviewed literature has not established CAD, PTSD or other psychological comorbidities, as a cause of CVA and noted that carotid imaging has confirmed cerebrovascular disease as the cause of the Veteran's CVA, which indicates that it was not related to cardiac conditions. The examiner further explained that CAD and CVA share risk factors but are considered separate, individual conditions. This opinion is consistent with a prior January 2021 VA opinion, which noted that a detailed work-up at the time of the stroke had not revealed signs of arrhythmia. The April 2021 VA examiner also noted that the scientific literature does not establish herbicide agent exposure as a cause of CVA, and explained that there is no anatomic or physiologic mechanism by which PTSD and related psychological comorbidities or CAD can aggravate the veteran's CVA/residuals beyond the natural course, adding that there is no evidence of aggravation of the Veteran's CVA and residuals beyond the natural course. The April 2021 VA opinion shows adequate consideration of the relevant evidence, to include the Veteran's service treatment record, his treatment records from the time of the CAV, and Dr. R.A.B.'s favorable medical opinion. It also addresses the concerns expressed by the Board in its March 2021 remand. This includes consideration of whether any residuals of the July 2010 cerebrovascular accident have at least as likely as not been aggravated (worsened beyond its natural progression) by his service-connected coronary artery disease or his service-connected PTSD. As such, it is worthy of significant probative weight. The Board further finds that the probative value of the April 2021 VA opinion outweighs Dr. R.A.B.'s favorable opinion. In this regard, the Board finds that the April 2021 VA medical opinion has rebutted Dr. R.A.B.'s opinion that the Veteran's CVA was due to his CAD. As discussed above, the April 2021 VA opinion discussed treatment records from the time of the stroke, which are negative for signs of arrhythmia. In contrast, Dr. R.A.B.'s opinion does not discuss these treatment records and there is no clear indication that he was able to review them. It should also be noted that Dr. R.A.B.'s has reported having done the Veteran's annual employment physicals in the period prior to the stroke. There is no indication that Dr. R.A.B.'s examined or treated the Veteran in the aftermath of the CVA. In sum, the weight of the competent and probative evidence is against a finding that the Veteran's CVA is related to service or secondary to a service-connected disability. A recent VA opinion establishes that the Veteran's CVA was caused by cerebrovascular disease, with no indication that it was caused by his cardiac condition. It also tends to show that the scientific and medical literature does not show a relationship between CVA and PTSD, or between CVA and herbicide exposure. Finally, regarding the aggravation prong of secondary service connection, the Board finds that the April 2021 VA opinion is consistent with the evidence of records, which fails to show that any CVA residuals have been aggravated by a service-connected disability. A January 2021 VA examination indicates that the Veteran's CVA residuals consisted of short-term memory loss and loss of balance, both of which were permanent. The April 2021 VA examiner explained that there is no anatomic or physiologic mechanism by which PTSD and related psychological comorbidities, or CAD, can aggravate the Veteran's CVA residuals beyond the natural course. The record does not contain competent evidence that rebuts this assertion. Similarly, the Board finds that the competent evidence does not tend to show that the Veteran's residuals have in fact been aggravated beyond their natural progression by the Veteran's service-connected disabilities. The Board also acknowledges the Veteran's assertion, to include in the April 2021 statement, that his cerebrovascular accident (CVA), or stroke, is proximately due to or the result of his service-connected heart disability. The Veteran in this matter is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing regarding the cardiovascular system. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. As such, his statements regarding etiology are not competent and lack weight. For these reasons, the preponderance of the evidence tends to weigh against a nexus to service or to a service-connected disability. Therefore, the claim of service connection for ischemic stroke is denied. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.