Citation Nr: 22021565 Decision Date: 04/12/22 Archive Date: 04/12/22 DOCKET NO. 20-12 609 DATE: April 12, 2022 REMANDED Entitlement to service connection for a stroke as secondary to service-connected diabetes mellitus, type II, is remanded. REFERRED Entitlement to service connection for hypertension has been raised by the record, including in the Veteran's March 2020 VA Form 9, so is referred to the agency of original jurisdiction (AOJ) for adjudication. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1966 to February 1970. This claim arises out of a September 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) which reopened and denied a claim of entitlement to service connection for stroke. The Veteran requested a Board hearing on his March 2020 VA Form 9. However, he withdrew his request for a Board hearing in February 2022 correspondence. Entitlement to service connection for a stroke as secondary to service-connected diabetes mellitus, type II, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a stroke because no VA examiner has opined whether the Veteran's hypertension and/or hyperlipidemia were caused or aggravated by the Veteran's diabetes mellitus, type II. The record persuasively establishes that both the hypertension and hyperlipidemia contributed to the transient ischemic attack (TIA), also referred to as a stroke and the Veteran has raised the issue of whether these conditions are intermediate steps between his diabetes and his TIA, so it is necessary to determine whether they are related to the Veteran's service-connected condition. In addition, the Veteran has raised the theory that his hypertension is directly related to his active service, including his conceded exposure to herbicide agents during his honorable service in the Republic of Vietnam during the Vietnam Era. Finally, the Veteran submitted significant medical treatise evidence contradicting the VA examiner's rationale, particularly on the point of whether it is medically relevant that the Veteran's diabetes was only diagnosed six months prior to his TIA. See March 2022 Appellate Brief (citing a research study published by the National Institute of Health indicating that diabetes and prediabetes are both risk factors for stroke and otherwise providing supporting evidence and argument contradicting the VA examiner's conclusory statements). Because the VA examiner cited no medical literature in support of her conclusory statement that "[t]ypically, if the stroke is caused by diabetes, it is a long term and not a short-term development." The Board is unable to apply this general treatise information to the particulars of this case, see, e.g., Sacks v. West, 11 Vet. App. 314, 316-17 (1998), however, the treatise information directly contradicts the VA examiner's unsupported statement of the only medical principle supporting her rationale. An opinion addressing this theory is necessary to decide the claim. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's transient ischemic attack (TIA) and residuals including: a. Whether the Veteran's June 2009 TIA was at least as likely as not proximately due to service-connected disability, particularly including the Veteran's diabetes mellitus, type II. b. If the answer to (a) is negative, whether the Veteran's June 2009 TIA was at least as likely as not aggravated by service-connected disability, particularly including the Veteran's diabetes mellitus, type II. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension including: a. Whether the Veteran's hypertension is at least as likely as not related to his active service, to include his conceded exposure to herbicide agents during his service in the Republic of Vietnam. In answering this question, it would be helpful if the examiner discussed the relevance, if any, of the National Academy of Science's Institute of Medicine 's "Veterans and Agent Orange: Update 11" concluded that there was "sufficient evidence of an association" between exposure to herbicide agents and hypertension. b. If the answer to (a) is negative, whether the Veteran's hypertension is at least as likely as not proximately due to service-connected disability, particularly including the Veteran's diabetes mellitus, type II. c. If the answer to (b) is negative, whether the Veteran's hypertension has been at least as likely as not aggravated by service-connected disability, particularly including the Veteran's diabetes mellitus, type II. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hyperlipidemia including: a. Whether the Veteran's hyperlipidemia is at least as likely as not proximately due to service-connected disability, particularly including the Veteran's diabetes mellitus, type II. a. If the answer to (a) is negative, whether the Veteran's hyperlipidemia has been at least as likely as not aggravated by service-connected disability, particularly including the Veteran's diabetes mellitus, type II. Brian LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kerry Hubers 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.