Citation Nr: 22017582 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 19-10 054 DATE: March 25, 2022 REMANDED Entitlement to service connection for head trauma residuals including concussion residuals, traumatic brain injury (TBI) residuals, a cerebral hemorrhage, and a brain disorder, is remanded. REASONS FOR REMAND The Veteran had active service from March 1960 to February 1964. In November 2019, the Board of Veterans' Appeals (Board) the Veteran's claim for service connection for a brain disorder to include head trauma residuals and a cerebral hemorrhage. The Veteran subsequently appealed to the Court of Appeals for Veterans Claims (Court). In September 2020, the Court granted the Parties' Joint Motion for Remand; vacated the November 2019 Board decision; and remanded the appeal for additional action consistent with the Joint Motion for Remand. Entitlement to service connection for head trauma residuals including concussion residuals, TBI residuals, a cerebral hemorrhage, and a brain disorder, is remanded. The service treatment records state that the Veteran was involved in an October 1962 motor vehicle accident and sustained head trauma. An October 1962 hospital discharge summary states that the Veteran sustained a cerebral concussion with loss of consciousness; a facial laceration; and pelvic fractures and was hospitalized for three weeks. The report of a November 2021 TBI examination conducted for the Department of Veterans Affairs (VA) states that the Veteran was diagnosed with a TBI in October 1962. The examiner concluded that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in service injury, event, or illness." The doctor commented that: "there is a partial medical record from October of 1962 that documents a motor vehicle accident associated with a facial injury and a likely concussion given the mechanism of injury;" "if he did suffer a TBI at that time it is likely to have been a mild TBI, and given his continued service and subsequent employment it is not likely that he had long term brain disorder from this 1962 injury;" "the medical records do document two more severe brain insults in 2013 and 2017, namely a traumatic brain injury from a bicycle accident including subarachnoid hemorrhage, and an occipital intraparenchymal cerebral hemorrhage, respectively;" "these are the likely causes of any current brain malfunctions and abnormal findings on neurological exam;" and "it is therefore less likely than not that a current brain disorder is incurred in or caused by the motor vehicle accident in service in October 1962." The Board observes that the examiner apparently did not review the October 1962 hospital summary and concurrently found that the Veteran sustained an October 1962 TBI and may not have sustained a TBI. Given these deficiencies, the Board finds that the November 2021 examination report is of essentially no probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA evaluation is needed. Clinical documentation dated after August 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records not already of record, including those pertaining to treatment after August 2021. 2. Schedule the Veteran for a VA neurological and TBI examination conducted by an appropriate specialist physician (either a psychiatrist, physiatrist, neurosurgeon, or neurologist) in order to determine the nature and etiology of the claimed head trauma residuals. The examiner should specifically state his medical specialty. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Confirm that the examiner is a physiatrist, neurologist, neurosurgeon, or psychiatrist. (b) Diagnose all head trauma residuals, including any vision disabilities found. If TBI residuals are not identified, the examiner should specifically state that fact and should reconcile that finding with previous findings of record. The examiner should consider the Veteran's lay statements regarding symptoms during and since service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified head trauma residuals had their onset during active service or are related to any incident of service, including the documented in service October 1962 motor vehicle accident and cerebral contusion. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.