Citation Nr: A25035178 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240814-464619 DATE: April 16, 2025 ORDER Entitlement to service connection for stroke, to include transient ischemic attack (TIA), as secondary to the Veteran's service-connected pre-syncopal episodes, is granted. FINDING OF FACT The Veteran's stroke, to include transient ischemic attack (TIA), was at least as likely as not caused by his service-connected pre-syncopal episodes. CONCLUSION OF LAW The criteria for service connection for stroke, to include transient ischemic attack (TIA), due to the Veteran's service-connected pre-syncopal episodes have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1981 to August 1992. In the August 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the August 2023 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. The Veteran is seeking service connection for stroke, to include transient ischemic attack (TIA). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for a current disability resulting from a service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310. The legal threshold for establishing secondary service connection is simple "but for" causation, which is a "broad standard" that allows for multiple causes of a harm. Spicer v. McDonough, 61 F.4th 1360, 1363-64 (Fed. Cir. 2023). Analysis The August 2023 rating decision by the AOJ provided a favorable finding that the Veteran is service connected for urinary incontinence, status-post lumbar microdiskectomy L5-S1, irritable bowel syndrome, plantar fasciitis bilateral, pre-syncopal episodes, cervical-thorax spine functional chronic mechanical myofascial strain, right lower extremity radiculopathy (sciatic), femoral right lower extremity radiculopathy, right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis, tinnitus, scar left side of face, and scar, status-post lumbar microdiskectomy. The AOJ also provided a favorable finding that the Veteran has been diagnosed with a disability: thrombosis, TIA cerebral infarction. The Board is bound by these favorable findings, unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 C.F.R. § 3.104(c). The Veteran contends that his stroke, to include transient ischemic attack (TIA), has been caused by his service-connected disabilities. The Veteran attended a VA examination in February 2023. The VA examiner was able to provide a diagnosis of history of left middle cerebral artery stroke with right-sided deficits following the stroke. The VA examiner was able to provide medical opinions that the Veteran's stroke-transient ischemic attack is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected urinary incontinence, status-post lumbar microdiskectomy L5-S1, irritable bowel syndrome, plantar fasciitis bilateral, cervical-thorax spine functional chronic mechanical myofascial strain, right lower extremity radiculopathy (sciatic), femoral right lower extremity radiculopathy, right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis, tinnitus, scar left side of face, and scar, status-post lumbar microdiskectomy. The VA examiner also provided rationales for the medical opinions as follows: Right lower extremity radiculopathy, sciatic nerve involvement. For the right lower extremity radiculopathy, the examiner provided a rationale that stroke-transient ischemic attack and right lower extremity radiculopathy, sciatic nerve are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from the right lower extremity radiculopathy, sciatic nerve, which occurs when one of your nerve roots (where your nerves join your spinal column) is compressed or irritated. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Right lower extremity radiculopathy, femoral nerve involvement. Regarding the Veteran's service-connected femoral nerve, right lower extremity radiculopathy, the VA examiner provided a rationale that stroke-transient ischemic attack and femoral nerve, right lower extremity radiculopathy are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from the femoral nerve, right lower extremity radiculopathy, which occurs when one of your nerve roots (where your nerves join your spinal column) is compressed or irritated. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Cervical-thorax spine functional chronic mechanical myofascial strain. For the rationale for the examiner's medical opinion that the Veteran's service-connected cervical-thorax spine functional chronic mechanical myofascial strain did not cause the Veteran's stroke-transient ischemic attack, the examiner stated that stroke-transient ischemic attack and cervical-thorax spine functional chronic mechanical myofascial strain are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from the cervical-thorax spine functional chronic mechanical myofascial strain, which is defined as a persistent neck discomfort for at least 3 months due to chronic mechanical stresses such as bad neck posture as well as degenerative changes and is unrelated to it. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis. Regarding the Veteran's service-connected right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis, the VA examiner provided a rationale that stroke-transient ischemic attack and right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from the right shoulder mild functional rotator cuff tendinosis and chronic subacromial bursitis, which is an inflammation of the tendons that make up the rotator cuff. The examiner further provided that the right shoulder condition is usually brought about by repetitive overhead activities or trauma, and a thorough review of medical literature failed to demonstrate a causal relationship. Microdiskectomy and associated scar. For the rationale for the examiner's medical opinion that the Veteran's service-connected microdiskectomy L5-S1 and associated scar did not cause the Veteran's stroke-transient ischemic attack, the examiner stated that stroke-transient ischemic attack and microdiskectomy and microdiskectomy scar are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from the microdiskectomy L5-S1, which is the surgical removal of herniated disc fragments which are pressing on the nerve root in the spine, and the associated scar is part of the normal healing process after spine surgery. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Urinary incontinence. Regarding the Veteran's service-connected urinary incontinence, the VA examiner provided a rationale that stroke-transient ischemic attack and urinary incontinence are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from urinary incontinence, which is the involuntary leakage of urine and unrelated to it. The examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Irritable bowel syndrome (IBS). For the rationale for the examiner's medical opinion that the Veteran's service-connected irritable bowel syndrome (IBS) did not cause the Veteran's stroke-transient ischemic attack, the examiner stated that stroke-transient ischemic attack and IBS are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from IBS, which is a common gastrointestinal condition defined by disturbances of bowel habits and abdominal pain in the absence of known organic pathology. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Bilateral plantar fasciitis. Regarding the Veteran's service-connected bilateral plantar fasciitis, the VA examiner provided a rationale that stroke-transient ischemic attack and bilateral plantar fasciitis are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from bilateral plantar fasciitis, which is the result of degenerative irritation of the plantar fascia originating at the medial calcaneal tuberosity of the heel as well as the surrounding perifascial structures. The examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Tinnitus. For the rationale for the examiner's medical opinion that the Veteran's service-connected tinnitus did not cause the Veteran's stroke-transient ischemic attack, the examiner stated that stroke-transient ischemic attack and tinnitus are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from tinnitus, which is the perception of sound in the absence of an actual external sound and represents a symptoms of an underlying condition rather than a single disease. The VA examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Scar left side of face. Regarding the Veteran's service-connected scar on the left side of his face, the VA examiner provided a rationale that stroke-transient ischemic attack and a scar on the left side of the face are not medically related, as stroke is defined as a transient episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury and is a separate entity entirely from a scar on the left side of the face, which is from a folliculitis biopsy and is unrelated to it. The examiner further provided that a thorough review of medical literature failed to demonstrate a causal relationship. Consideration of toxic exposure risk activities (TERA). In June 2023, the VA examiner also provided a medical opinion that the Veteran's cardiovascular accident was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effects of all toxic exposure risk activities of the Veteran. The examiner provided a rationale that the Veteran states that from 1988 to 1990 he worked as a classified inspector which required handling of powder residue on crates, and apparently the powder was radar absorbent material (RAM) which required handling with gloves and a respirator. The VA examiner further provided that the Veteran stated that he was always compliant with wearing the required protective gear without exception and is unaware of any other potential exposures to toxins or toxic material. The examiner concluded that, had the Veteran been exposed to RAM, no evidence is found to suggest this would provide a reasonable causal explanation for the CVA, and a more reasonable explanation is his history of chronic hypercholesterolemia and hypertension noted in clinical records dated December 2013. Pre-syncopal episodes. However, in February 2023, the VA examiner provided a medical opinion that it is at least as likely as not that the Veteran's stroke-transient ischemic attack (claimed as stroke-TIAs) is proximately due to or the result of his pre-syncopal episodes. The examiner provided a rationale that the Veteran does state that he has had long-standing pre-syncopal episodes, particularly accompanying vertigo and/or when rising from sitting to standing. The VA examiner further provided that the Veteran does indeed have this documented in his chart prior to his stroke and while vertigo is not a precursor to stroke, as it is a disease of the inner ear and not the brain, orthostatic hypotension can be a risk factor for stroke as it implies there is decreased oxygenation to the brain. As the evidence weighs in favor of the Veteran, the Board finds that the Veteran's stroke, to include transient ischemic attack (TIA), is at least as likely as not caused by the Veteran's pre-syncopal episodes. Service connection for stroke, to include transient ischemic attack (TIA), as secondary to the Veteran's service-connected pre-syncopal episodes is warranted. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Merriam, Jeffrey 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.