RESIDUALS OF ENCEPHALITIS

TIFFANY DAWSON · 2026 · Case ID: A26031127

GRANTED

Summary

The Veteran, a Veteran who served from October 2006 to December 2008, including combat service in Iraq as part of Operation Iraqi Freedom, appeals the denial of service connection for Traumatic Brain Injury (TBI) and headaches secondary to TBI. The Veteran initially alleged TBI from IED blasts in 2008, but later provided a statement detailing a fall down stairs in March 2007 at the School of Infantry, which caused a loss of consciousness and subsequent headaches. Service records confirm combat participation in Iraq. VA treatment records from December 2010 indicated a TBI diagnosis consistent with the injury sustained during deployment, noting three episodes of altered consciousness, including a fall down stairs. The Veteran also reported constant headaches since that event and continued treatment for headaches as of September 2020. The Board found the Veteran's statements and lay evidence credible, noting the consistency with the in-service events and subsequent symptomatology. Applying the benefit of the doubt, service connection for TBI residuals (balance problems/dizziness, sleep problems) and headaches was granted. The Board found the evidence established current residuals and a nexus to service, particularly given the combat service and the relaxed evidentiary standards under 38 U.S.C. § 1154(b).

Rationale

Current residuals established; Nexus to service established; Benefit of the doubt applied

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210105-130687

Full Decision Text

Citation Nr: A26031127
Decision Date: 04/06/26 Archive Date: 04/06/26

DOCKET NO. 210105-130687
DATE: April 6, 2026

ORDER

Entitlement to service connection for a traumatic brain injury (TBI) is granted.

Entitlement to service connection for headaches is granted.

FINDINGS OF FACT

1. The Veteran suffered in-service head injuries on at least two occasions during his active-duty service that resulted in a TBI with at least two current TBI residuals, balance problems or dizziness and sleep problems.

2. The Veteran suffered in-service head injuries on at least two occasions during his active-duty service that resulted in headaches.

CONCLUSIONS OF LAW

1. The criteria for service connection for TBI residuals, to include balance problems or dizziness and sleep problems, have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.303.

2. The criteria for service connection for headaches have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 2006 to December 2008.

The rating decision on appeal was issued in December 2020 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the January 5, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on July 18, 2024; a transcript is associated with the claims file. Therefore, the Board may only consider the evidence of record at the time of the December 2020 Agency of Original Jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing, i.e., until October 16, 2024. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, then 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, then VA will issue another decision on the claims, 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 seeks entitlement to service connection for a TBI as well as headaches secondary to a TBI.

Specifically, on his initial June 2020 claim form, the Veteran alleged that he sustained a TBI as a result of multiple improvised explosive device (IED) blasts with loss of consciousness in combat in approximately 2008. In correspondence dated in August 2024 (received within 90 days of the Veteran's July 2024 Board virtual hearing), the Veteran indicated that he fell out of the back of a 7-ton truck while wearing his backpack, landed on his head, and momentarily lost consciousness while training at the School of Infantry in approximately March 2007.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§1110, 1131, 5107; 38 C.F.R. §3.303. Generally, establishing service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

The Board "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases." Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). The AOJ, in its adjudication manual (the M21-1), defines terms central to this appeal for residuals of a TBI. Part V, sbpt. iii, ch. 12
ation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

First, the AOJ defines a TBI as "the physical, cognitive, and/or behavioral/emotional residual disability resulting from an event of external force causing an injury to the brain."

Second, the AOJ defines a "TBI event" as "a traumatically induced structural injury and/or physiological disruption of brain function resulting from an external force indicated by at least once of the following clinical signs immediately following the event: "any period of loss of consciousness or decreased consciousness; any loss of memory for events immediately before or after the injury; any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.); neurological deficits, whether or not transient; or intracranial lesion."

The AOJ further notes that a "TBI event has two necessary components: the external force and the identifiable acute manifestations of brain injury immediately following the external force. Not all individuals exposed to an external force will have brain injury, and therefore, they will not meet the criteria for having a TBI event. The acute manifestations may resolve without chronic disability, or a chronic disability may result. Although unconsciousness or reduced consciousness is common in TBI events, these are not required. Any one of the five signs will be sufficient."

Third, the AOJ defines an "external force" as any of the following events: "a foreign body (such as a bullet or shell fragment) penetrating the brain; the head being struck by an object (such as a fist, a hatch, or flying debris); the head striking an object (such as the ground or a windshield); the brain undergoing an acceleration/deceleration movement without direct external trauma to the head; force generated from events such as a blast or explosion; or other force yet to be defined."

In addition, "TBI events may occur during combat or non-combat situations (such as a motor vehicle accident, fall, or personal assault)."

Fourth, the AOJ defines "TBI residuals" or "TBI sequelae" as "the resultant disabling effects of a TBI event beyond those that follow immediately from the acute injury to the brain." Moreover, "the signs and symptoms of TBI residuals can be organized into the three main categories of physical, cognitive, and behavioral/emotional residuals for evaluation purposes."

The AOJ also has identified examples of TBI residuals in each of the three categories. These include, but are not limited to, those listed below: Physical, Cognitive, Behavioral/Emotional: apraxia (inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness); dementias (pre-senile Alzheimer's type, dementia pugilistica, post traumatic dementia); depression; aphasia (difficulty communicating orally and/or in writing); attention and concentration deficits; agitation and irritability; paresis (muscle weakness or incomplete paralysis); memory, processing, and learning impairment; impulsivity; plegia (paralysis or stroke); language deficiencies; aggression; dysphagia (difficulty swallowing); planning difficulties; anxiety; disorders of balance and coordination; judgment and control difficulties; posttraumatic stress disorder; diseases of hormone deficiency; reasoning and abstract thinking limitations; Parkinsonism; self-awareness limitations; nausea/vomiting; headaches; dizziness; blurred vision; seizure disorder; sensory loss; weakness; and sleep disturbance.

The Board applies them in the instant case to clearly and fully articulate the Board's understanding of these terms and the benchmark employed in reaching its conclusion. Id.; see also LeMon v. McDonough, No. 21-3949, 2022 U.S. App. Vet. Claims LEXIS 1998, *7 (Dec. 16, 2022) (mem dec) (Toth, J.).

Here, a review of the Veteran's service treatment records reveals a March 2008 Post-Deployment Health Assessment on which the Veteran assessed his general health at the time as "somewhat worse" than before he deployed to Iraq. The Veteran reported physical health problems which made it "very difficult" for him to do his work or other regular daily activities in the prior four weeks. Additionally, he reported emotional problems (such as feeling depressed or anxious) which made it "somewhat difficult" for him to do his work or other regular daily activities in the prior four weeks. Specifically, the Veteran reported muscle aches; swollen, stiff or painful joints; back pain; numbness or tingling in hands or feet; as well as increased irritability which still bothered him. He also indicated that he was constantly on guard, watchful, or easily startled; felt numb or detached from others, activities, or his surroundings; and had little interest or pleasure in doing things nearly every day. However, the Veteran did not indicate whether or not he experienced memory problems or lapses; balance problems or dizziness; ringing in the ears; sensitivity to bright light; irritability; headaches; or sleep problems. As such, the clinician indicated that there was no evidence of risk of a TBI.

Service personnel records confirm that the Veteran served in combat as part of Operation Iraqi Freedom from September 2007 to April 2008.

A review of the Veteran's VA treatment records include a December 2010 TBI screening in which he reported balance problems or dizziness, headaches, and sleep problems. Later that month, at a TBI Secondary Screening Consult, the physician concluded that the history of the injury and the course of clinical symptoms were consistent with a diagnosis of TBI sustained during Operation Iraqi Freedom deployment. At that time, the Veteran reported three episodes of alterations in consciousness during his deployment. The most notable event occurred in December 2007, at which time he fell down full flight of stairs while clearing a house and suffered an alteration in consciousness (feeling "dazed and confused"). The Veteran further indicated that he suffered from "constant" headaches since that event. The Veteran also reported two improvised explosive device blasts (estimated to be 150 meters away) while on foot patrol. However, he sought no medical treatment after those events and continued on his mission. VA treatment records dated as recent as September 2020 show that the Veteran is still being treated for headaches.

As this evidence establishes current TBI residuals (to include balance problems or dizziness and sleep problems) as well as headaches, the Board finds that the first requirement of service connection has been met.

Moving forward to the second element for service connection, the Veteran's military personnel records confirm his combat participation in Iraq. Thus, the Board finds that the Veteran engaged in combat. 38 U.S.C. § 1154 (b) permits relaxed evidentiary standards for certain veterans determined to have been engaged in combat to establish the incurrence or aggravation of a disease or injury in service based on a recognition that official records documenting proof of service connection during combat situations may be unavailable or nonexistent. See Maxson v. Gober, 230 F.3d 1330, 1332 (2000); see also Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012).

As such, the Board finds that the Veteran's contentions that his current TBI residuals and headaches began as a result of falling on his head as well as exposure to two improvised explosive devices are supported by his combat experience. Therefore, the Board accepts the Veteran's statements as both competent and credible. Consequently, the Board finds that his TBI residuals and headaches had their onsets in service and the second element of service connection is established.

However, Section 1154(b) does not eliminate the need for evidence of a current disability or nexus; it merely reduces, for veterans who have engaged in combat with the enemy, the burden of presenting evidence of in-service incurrence or aggravation of a disease or injury. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996) ("Section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service-connected).

To that end, the Veteran submitted several lay statements in
credible. Consequently, the Board finds that his TBI residuals and headaches had their onsets in service and the second element of service connection is established.

To that end, the Veteran submitted several lay statements in support of his claims.

In correspondence dated in July 2024 (and submitted within 90 days of the Veteran's July 2024 Board hearing), a childhood friend who later served with the Veteran in boot camp and the School of Infantry indicated that he witnessed the Veteran fall out of a flatbed truck and land on his head while trying to juggle his gear while at the School of Infantry. This service member also indicated that the Veteran often experienced headaches during the following years which he never experienced prior to service. He explained that it was "frowned upon" to go to medical during their time in the U.S. Marines, and that they endured the pain and took anti-inflammatory medications so that they could keep moving forward.

In correspondence dated in August 2024 (and submitted within 90 days of the Veteran's July 2024 Board hearing), the Veteran's spouse indicated that she met the Veteran in 2011 (approximately three years following his separation from service) and that he had experienced headaches and migraines since that time. She also reported that she observed a decline in the short-term memory and cognitive ability of the Veteran to the point where she took over the responsibility of handling the family's finances.

In correspondence dated in September 2024 (and submitted within 90 days of the Veteran's July 2024 Board hearing), a former service member who served with the Veteran while assigned to the Kilo Company, 3rd Battalion, 5th Marine Regiment, from May 2007 to November 2008 indicated that he witnessed the Veteran in a "dazed" state after a senior Marine set off an artillery shell simulator a few feet from the edge of a tent where the Veteran was laying during Combined Arms Exercise at Twentynine Palms, California, in 2007. This service member further reported that the Veteran fell hard down a flight of cement stairs while holding the platoon radio on a combined patrol in Iraq, after which time the Veteran could not hold a conversation, routinely drifted off in speech, and could not rest due to throbbing headaches.

In correspondence also dated in September 2024 (and submitted within 90 days of the Veteran's July 2024 Board hearing), the Veteran Service Officer representing the Veteran indicated that the Veteran struggled with staying on topic and became confused while conversing at the time of his July 2024 Board hearing, which he attributed to TBI residuals.

The Board finds the Veteran's own statements as well as the lay statements submitted in support of his claims to be credible as to the Veteran's symptomatology in service and in the years following service.

In sum, due to the credible and competent evidence of TBI residuals and headaches during, and since, combat service; the December 2010 TBI Secondary Screening Consult in which a physician concluded that the history of the injury and the course of clinical symptoms were consistent with a diagnosis of TBI sustained during Operation Iraqi Freedom deployment; and resolving all reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for a TBI and headaches is warranted. Accordingly, the claim is granted. 38 U.S.C. §5107(b), Lynch, 21 F.4th at 776.

Tiffany Dawson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Flamini, Anthony

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.

Analyze in VA Law Explorer