Citation Nr: 21042834 Decision Date: 07/14/21 Archive Date: 07/14/21 DOCKET NO. 15-15 557 DATE: July 14, 2021 ORDER Service connection for stroke is granted. FINDING OF FACT The Veteran's stroke was caused or aggravated by his service-connected diabetes mellitus, type 2. CONCLUSION OF LAW The criteria for service connection for a stroke/stroke residuals have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION In June 2013, the RO denied this claim. The Veteran appealed, and in March 2019, the Board denied the claim. In July 2020, the Court vacated and remanded the Board's March 2019 decision. A private medical opinion received in June 2021 raises the issue of entitlement to service connection for hypertension. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board therefore does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9 (b). 1. Service connection. The Veteran asserts that service connection for residuals of a stroke is warranted as caused or aggravated by his service-connected diabetes mellitus, type 2. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303 (d). Service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). A brain hemorrhage, and brain thrombosis, can be service connected on such a basis. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Service connection is currently in effect for disabilities that include diabetes mellitus, type 2, and nonobstructive coronary heart disease. In November 2011, the Veteran sustained a left occipital infarction in the PCA (posterior cortical atrophy) territory consistent with emboli, although no source could be found. Transthoracic echo with bubble was normal and transcranial Doppler showed no emboli. An MRI showed chronic occlusion of the previously seen restricted diffusion in the left parieto-occipital lobe. VA progress notes dated in March 2012 note that his risk factors for stroke include age, gender, hypertension, hyperlipidemia, and type 2 diabetes mellitus. A VA examination report, dated in June 2012, shows that the examiner concluded that it was more likely than not that the Veteran's history of CVA (cerebrovascular accident) was related to, or aggravated by, his diabetes mellitus. The examiner explained that this condition predated his diagnosis of diabetes mellitus. A March 2013 central nervous system disability benefits questionnaire (DBQ) shows that the Veteran was noted to have a history of beginning treatment for diabetes in 2009 and that it worsened in 2011. His first CVA was in November 2011, with further strokes four and 8 days after his initial attack. There were recent findings that his CVA was related to a vertebrobasilar insufficiency or embolic phenomena. The diagnosis was thrombosis, TIA, or cerebral infarction with a date of November 2011. The examiner concluded that it is at least as likely as not that the Veteran's CVA is proximately due to, or the result of, his service-connected diabetes mellitus. The examiner explained that the Veteran's multiple infarcts and vertigo are a result of small vessel disease related to diabetes, a service connected disease that has brought on symptoms in an area of his brain that was previously functioning with mild impairment, made symptomatic and critical by the small vessel disease related to diabetes. The Veteran's MRI of the brain clearly shows multiple small infarcts related to small vessel disease, a condition with definite association with diabetes. A VA examination report, dated in April 2013, shows the following: The examiner stated that the March 2013 examination had been reviewed, and that, "It is found to carry low probative value due to an apparent misunderstanding of purpose. The various responses given in section 3 of the contract exam may reflect the veteran's overall health but do not necessarily indicate residuals of stroke which are needed for C&P (Compensation and Pension) purposes." The March 2013 VA examiner discussed several types of symptoms that have no relationship to his stroke, to include sleep and gastrointestinal symptoms. The Veteran has three known risk factors for stroke: dyslipidemia, hypertension, and diabetes. His lipid profile places him at significantly increased risk for stroke. The Veteran takes hydrochlorothiazide and Lisinopril for hypertension, which is a strong risk factor for stroke. The Veteran's diabetes has only emerged in the last few years. The Veteran's serious dyslipidemia and longstanding hypertension appear to outweigh diabetes that has recently emerged. There does not appear to be a question of equipoise with respect to diabetes. In effect, in this case, the Veteran's stroke is less likely than not proximately due to or the result of diabetes. Emboli to the territory of the left posterior cerebral artery were less likely than not proximately due to or the result of service-connected type II diabetes mellitus. An opinion from a VA physician, M.B., M.D., dated in July 2018, shows that Dr. M.B. states that it is more likely than not that the Veteran's diabetes caused his stroke "and the residuals thereof." In October 2018, the Board requested a VHA medical opinion. See 38 C.F.R. § 20.901 (a). In November 2018, an opinion was received from P.N., M.D. Dr. P.N. states the following: The Veteran was diagnosed with diabetes sometime after December 2010, however, he was started on Metformin in 2008 for impaired glucose control. He has a long history of hypertension and dyslipidemia with elevated triglycerides dated to 2008. A month after his documented diagnosis of diabetes mellitus he was diagnosed with a subacute stroke, meaning it occurred at least four weeks prior to the diagnosis. Dr. P.N. concluded that it is not as likely as not that the Veteran's strokes were caused by, or aggravated by, his diabetes mellitus, citing to findings for his A1c (hemoglobin) levels between 2010 and 2016, indications that his stroke was embolic, and evidence that his diabetes mellitus was not in poor control prior to his stroke. An opinion from J.K., M.D., submitted by the Veteran in June 2021, shows the following: The Veteran was suffering from impaired fasting glucose since at least March 2008, which could have caused microvascular damage. There is evidence of nephropathy beginning in 2009. These conditions could have been contributing to cerebral vascular damage since those times. Pre-diabetes and diabetes are well-established risk factor for strokes. Patients with diabetes are particularly at a significantly higher risk of stroke. There are several possible mechanisms for this, to include it causing pathologic changes in blood vessels at various locations and can lead to stroke if cerebral vessels are directly affected. Dr. J.K. concluded that it is at least as likely as not that the Veteran's hypertension was caused by his exposure to herbicides, including Agent Orange, during his service in Vietnam. Dr. J.K. further concluded that it is at least as likely as not that the strokes the Veteran experienced in 2011 and 2012 developed secondary to his hypertension. Several studies have shown that diabetes is known to influence almost all varieties of strokes, including large artery strokes due to atherosclerosis, intracerebral hemorrhages due to microvascular injury, and embolic strokes. There is no way to medically determine which of the Veteran's stroke risk factors, i.e., hypertension or diabetes, played a more predominant role in his cerebrovascular disease. While not all opinions are presumed to have equally probative value, the Board first notes that there are four opinions of record in favor of the claim, and two opinions against the claim. In this case, Dr. J.K.'s opinion is found warrant significant probative value, such that when it is taken together with the other positive opinions of record, the evidence against the claim is in balance with the evidence in favor of the claim. VA regulations dictate that if the evidence is in relative equipoise, then the benefit of the doubt must be resolved in the appellant's favor. 38 U.S.C. § 5107 (b). That is the case here. Accordingly, service connection for stroke is granted. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S.E., 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.