Citation Nr: 0007985 Decision Date: 03/24/00 Archive Date: 03/28/00 DOCKET NO. 94-28 609 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York THE ISSUE Entitlement to a rating in excess of 10 percent for residuals of a brain stem event. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Debbie A. Riffe, Associate Counsel INTRODUCTION The veteran served on active duty from July 1982 to July 1986 and from August 1986 to March 1991. This case comes to the Board of Veterans' Appeals (Board) from a February 1992 RO decision which granted service connection and a 10 percent rating for residuals of a brain stem event. (Subsequent rating decisions styled the service-connected disorder as amnestic syndrome due to a brain stem event.) The veteran appeals for a higher rating. In March 1997 and December 1998, the Board remanded the case to the RO for additional development. FINDINGS OF FACT 1. The veteran's service-connected residuals of a brain stem event are manifested by left-sided hemiparesis and hemisensory deficit, and the associated disability is equivalent to mild incomplete paralysis of the circumflex and sciatic nerves. 2. The veteran's service-connected residuals of a brain stem event are also manifested by psychiatric symptoms of cognitive and memory deficit, which are productive of mild social and occupational impairment. CONCLUSIONS OF LAW 1. Residuals of a brain stem event include neurological impairment of the left upper extremity which is noncompensable, and neurological impairment of the left lower extremity which is 10 percent disabling. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Codes 8008, 8518 8520 (1999). 2. Residuals of a brain stem event also include psychiatric impairment which is 10 percent disabling. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Codes 8008, 8045 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9304 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9304 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty in the Navy from July 1982 to July 1986 and from August 1986 to March 1991, as a machinist mate. On examinations for enlistment purposes in October 1981 and for separation purposes in May 1986, the veteran reported on a medical history form that he was right- handed. His service medical records indicate that in May 1990, while at a wedding, he had an acute onset of double vision and fell to the ground with momentary loss of consciousness. Upon awaking, he had significant difficulty walking and was weak on the left side. He underwent testing at a civilian hospital, and a magnetic resonance imaging (MRI) of the head revealed a lesion in the right brain stem. The veteran was presumed to have had a stroke; a full vasculitis workup was negative. He showed gradual functional improvement but continued to complain of double vision and ataxia. He walked with a cane. In June 1990, the veteran underwent an evaluation at a Naval hospital for possible stroke. On a medical board report, the veteran reported subjective diplopia. An examination revealed that his sensation was impaired to cold and vibration on the left side and his coordination was slow bilaterally. His gait was slow and ataxic, and he had difficulty walking with or without a cane. He took one aspirin a day for stroke prophylaxis. The diagnosis was acute brain stem event due to either a stroke or multiple sclerosis. He was deemed fit for limited duty for a period of six months. In December 1990, the veteran was seen in the psychiatry clinic for complaints of an inability to cope and severe exacerbation of stress. He reported excessive sleepiness and fatigue, difficulty with short term memory, and a weak attention span. A mental status examination revealed him to be alert, oriented times four, and appropriately groomed. His mood was euthymic and his affect was broad. There were no hallucinations, delusions, or suicidal/homicidal ideation. The diagnosis was other life circumstance problem (Axis I); there was no Axis II diagnosis. Also in December 1990, the veteran was reevaluated at a Naval hospital for possible stroke versus new onset of multiple sclerosis. His complaints consisted of chronic fatigue since the brain stem event, poor attention span, positional vertigo associated with black tunnel vision on positional changes, brief episodes of diplopia lasting seconds, and fear of lifting/stress/heat (i.e., fear of recurrence of brain stem event). An examination revealed the veteran was alert and oriented. His head, eyes, ears, nose, and throat were normal. The cranial nerves 2 through 12 were normal. His motor strength was 5/5 without drift. The sensory examination was intact to light touch and stereognosis. The reflexes were 2+ and symmetric. His coordination and gait were intact, and Romberg's sign was negative. It was noted on the medical board report that the veteran had a difficult time recovering from his acute brain stem event and had a prolonged period of anxiety coping with his resolving disease process (he had been diagnosed with life circumstance problem with no Axis II diagnosis). He was presently limited by his intermittent attacks of vertigo, poor attention span, and chronic fatigue. The diagnosis was acute brain stem event in June 1990, most consistent with a posterior circulation infarction, etiology unknown after extensive work-up. The veteran's case was referred to a physical evaluation board (PEB), and in February 1991 the PEB found the veteran physically unfit for duty with a determination that his disorder was 10 percent disabling. The veteran was discharged from service in March 1991 with severance pay due to his residuals of a brain stem event. On a VA neuropsychiatric examination in June 1991, the veteran complained of hypersomnia, easy fatigability, and memory difficulty since his stroke. He complained of pain and a throbbing sensation on the left side of his body. He was without psychiatric complaint. He reported that he was motivated to work but was unable to do so. He stated that his activities consisted of watching television and fishing. On mental status examination, the veteran was alert and cooperative. He carried a cane and appeared to have left- sided weakness. He described his mood as "grumpy" every once in a while. His affect was warm and pleasant. There were no perceptual problems and his speech was normal. His thought content revealed some angry feelings about having a stroke. He was not suicidal, homicidal, or otherwise psychiatrically disordered. His cognitive examination was remarkable in that he remembered two of three objects after five minutes. His concentration was intact. He was deemed competent to handle funds. There was no diagnosis of a psychiatric disorder (Axis I or II), and the veteran's Global Assessment of Functioning (GAF) scale score was 35 (current and past year). On a VA neurological examination in June 1991, the doctor noted that the veteran surprised him when he did not know too much about his condition but claimed that he probably had a stroke or demyelinating condition. The veteran appeared for the examination with a cane and reported that his left leg was painful. He reported that he did not take any medication. The doctor indicated that the veteran's neurological examination was essentially within normal limits and that no focal neurological deficits could be found. In the diagnosis, the doctor stated that the veteran was found to be essentially normal neurologically but referred him to the neurology clinic because he had a history of questionable stroke or multiple sclerosis. On a VA orthopedic examination in June 1991, the veteran complained that he had dizzy spells with loss of balance (for which reason he used a cane) and throbbing and shakiness in the left lower extremity with pain radiating from the left ankle and foot up to the left knee. He stated that lying down and resting brought complete relief of these symptoms. On examination, the veteran was very functionally ambulatory using a cane. Without the cane, he had a normal gait. There was absolutely no weakness or atrophy throughout the left lower extremity, and the tone of muscle throughout both lower extremities was normal. The examiner noted the veteran had familial bilateral pes cavus but that it was asymptomatic. There was full and strong mobility of both knees. Both knees and ankles were stable. The left ankle and foot were anatomically the same as the right, with no manipulation, pain, or tenderness on the left. The range of motion was the same on the left as the right. In the diagnosis, the doctor stated that the veteran had no actual orthopedic disability other than his complaints to the left lower extremity or residuals of the stroke he suffered. Subsequent X-rays of the left knee and left foot were negative. On a VA general medical examination in July 1991, the veteran's complaints included pain and occasional weakness of the left foot and leg, and a history of occasional (and what appeared to be orthostatic) dizziness. The doctor stated that real vertigo causing dizziness was not detected. The veteran reported that following the brain stem event in service he regained most of the function in his left upper and lower extremity but walked with a cane due to occasional balance disturbance. The doctor stated that the veteran was very vague on the history of his illness (and the doctor was unsure whether this involved the veteran's complaint of memory loss) but that the veteran seemed to have a good memory for all other questions posed to him. The veteran reported some anxiety secondary to the occurrence of the brain stem event. He reported taking a baby aspirin daily. On examination, there was no cyanosis, clubbing, or edema in the extremities. The veteran had equal muscle bulk and muscle strength throughout. His reflexes were 1+ and his toes were downgoing. Cranial nerves 2 through 12 were intact. Cerebellar function was normal. Romberg's sign was normal. In the diagnosis, the doctor stated that the veteran had a history of some type of a right brain stem lesion and some vague history of a stroke or a transient ischemic attack in 1990 (the doctor indicated that there was no documentation at hand of this). The doctor stated that the veteran had no neurologic findings and appeared healthy, that he only had complaints of some orthostatic problems, and that his memory appeared to be very good. An August 1991 VA outpatient record indicates a complaint of memory problems. An examination showed the veteran to be alert and oriented times three. There was no aphasia or dysarthria in his speech. His memory for recent events was intact. There was no facial asymmetry. His tongue was midline. On motor examination, there was no muscle atrophy or fasciculation. His strength was 5/5 throughout. His sensory functioning was intact to all modalities. Reflexes were 2 or 2+ in both lower extremities. The impression was stroke versus demyelinating disease. In September 1991, the veteran was admitted to the VA hospital for an MRI study. His major complaint was some dizziness and the need for occasional support in walking. He also reported loss of taste off and on and some memory loss. On physical examination, the veteran was alert and cooperative. His cranial nerves were okay. His gag reflex was present and his strength was 5/5 in the upper and lower extremities. His sensory function was okay, and his reflexes were present and symmetrical in the upper and lower extremities. Babinski's sign was negative. Cerebral finger- to-finger and finger-to-nose were within normal limits. A neurological examination was benign, with no gross deficits. An electroencephalogram (EEG) was normal. The MRI was scheduled to be performed on an outpatient basis. The veteran was discharged without any medications or follow-up in the hospital. A September 1991 MRI study conducted by the Health Science Center of the State University of New York shows an approximately 3 mm. focus of abnormal signal intensity in the right thalamus just lateral to the midline and extending just posterior to the right red nucleus, which may represent a focal demyelinating lesion or perhaps may be related to vascular insult. On a November 1991 VA neuropsychological screening evaluation, the veteran stated that he forgot his first appointment, but he presented on time for the second one. It was observed that he was alert, well oriented, cooperative, friendly, and appropriately dressed and groomed. His speech was clear, coherent, and relevant with no signs of dysarthria, dysphasia, or thought disorder. His affect was appropriate but occasionally mildly anxious. Frustration tolerance and concentration were good. Neuropsychological testing indicated the absence of a dementia-like disorder or any major generalized lowering of intellectual functioning. There was evidence of a mild to moderate problem with reading comprehension and suggestions of mild difficulties with the fund of remote memory and with half hour delayed recent memory, which were suggestive of provisional diagnoses of dyslexia and a partial organic amnestic syndrome (POAS). In a February 1992 decision, the RO granted service connection for residuals of a brain stem event and assigned a 10 percent rating. In September 1992, the veteran underwent additional VA neuropsychological testing to assess his current level of functioning. The test results did not show significant change from the previous evaluation in November 1991; they were indicative of a diagnosis of POAS and suggested the presence of a depressive disorder, not otherwise specified, and facets of psychological problems affecting physical condition. It was noted that prior testing had showed evidence of dyslexia which may be related to the veteran's brain syndrome. The evaluator recommended a repeat neurological examination wherein special attention could be directed to ruling out a progressive demyelinating disease versus a vascular disorder, either of which may be affecting more than one area of the central nervous system. On a VA psychiatric examination in April 1993, the veteran reported that he had had great difficulty in finding employment and that he recently obtained a job with a local manufacturing firm. He complained of frequent headaches, episodes of light-headedness upon standing, inability to cross his legs without his left foot becoming numb, throbbing in his left side if he became tired, soreness in his left shoulder, and difficulty with long term memory. He denied depressive and anxiety symptoms and reported he slept adequately. He reported difficulty concentrating at times and low energy. He noted he was fearful about performing many physical activities due to his stroke. On mental status examination, the veteran was fully oriented, neatly dressed, and made good contact. His speech was coherent and relevant. His affect was somewhat blunted but appropriate to content, and he was able to smile appropriately. He reported a sense of loss about things he was unable to do because of his stroke, but he denied suicidal ideas or plans. Memory testing was not performed due to extensive past testing, although the veteran complained of difficulty in remembering appointments. His judgment and insight seemed fair. The diagnoses were amnestic syndrome secondary to cerebral vascular accident, and the veteran's GAF score was 60 (current and past year). He was deemed competent to handle funds. On VA examination for brain disorders in March 1994, the veteran reported he was working at the post office. He noted he took one baby aspirin a day. He complained of some twitching in his face and some problems with the left leg. On examination, he was intact neurologically. In the diagnosis, the doctor stated the veteran was found to be essentially normal neurologically. He noted the veteran was status post brain stem injury, probably a small stroke, which was confirmed by MRI. The doctor recommended continued follow-up care. On a VA psychiatric examination in September 1997, the veteran complained of dizzy spells and leg cramps at times, recurrent severe headaches, short term memory loss and difficulty learning new material, and decreased sleep (due to leg cramps and headaches). He denied any change in the level of activity or interest or enjoyment of activities. He reported that he has worked at the post office for the past four years and denied missing any work due to the specified complaints. The veteran stated that he was not being treated by any psychiatrist or receiving any psychotropic medications, and that he had never been hospitalized for psychiatric reasons. On mental status examination, the veteran showed no significant psychomotor agitation or retardation. There were no tremors or abnormal movements. He was cooperative, although he expressed disappointment and anger for unfair treatment by VA. His speech was of normal rate, rhythm, and tone. His mood and affect were within normal limits. He showed no formal thought disorder. He had no hallucinations or delusions, and showed no significant symptoms for a mood or anxiety disorder. His cognition was grossly intact. Significant memory impairment was not detected during the interview, but the veteran had some difficulty remembering exact dates of the different events in his past history. His insight and judgment were good. The impression was amnestic disorder, not otherwise specified, and the veteran's GAF score was 61-70, which was related to his mild symptoms and difficulty in social and occupational life. The examiner commented that it would be very essential to know the site of the veteran's lesion, especially since there seemed to be a controversy over whether he sustained a brain stem lesion versus a thalamic lesion, because the location of the infarct would indicate the extent of his symptoms, especially the one related to his memory. The examiner stated that usually brain stem infarcts would not cause significant memory impairment, whereas a thalamic lesion might cause memory problems. The veteran was deemed competent to handle funds. On a VA neurological examination in May 1999, the veteran complained of persistent cramps, fatigability, and pain in the left lower extremity, especially below the knees. He also complained of some increased weakness in the left upper extremity, especially more since left shoulder dislocation surgery one year ago. He complained of neck pain, left shoulder pain, and left upper extremity pain proximally occasionally. He complained of short and intermediate memory problems since the stroke. He stated he forgot names and numbers occasionally but that it did not significantly affect his job. He stated that he took Advil tablets daily for his left-sided symptoms with significant relief. He reported having migraine headaches about once a month for which he took Midrin with significant relief. He reported occasional dizzy spells associated with light-headedness, nausea, and gait imbalance lasting one to two seconds without sequelae on one or two occasions a week. He denied any visual symptoms currently or any problems with walking and balance. He noted that his problems had limited his outdoor activities. He reported taking one baby aspirin a day. On mental status examination, the veteran was alert, awake, and oriented to person, place, and time. He talked coherently without any evidence of dysarthria or aphasia. He had immediate recall of two out of three after three minutes. He could spell forwards and backwards. Examination of his cranial nerves showed no defect except for diplopia on the left and gaze. His tongue was midline with positive gag reflex. On motor examination, there was no weakness in the right side. The left lower extremity showed some "give away" weakness. The left upper extremity was somewhat limited due to left shoulder pain, but there was no apparent weakness. The was decreased sensation to pin prick in patchy distribution on the left side. The reflexes were symmetric on both sides and both dorsal plantar flexion. The veteran was steady while walking, and he could walk on toes, heels, and do normal tandem walking. The assessment was history of stroke in 1990 with probable questionable left-sided hemiparesis and hemisensory deficit and some cognitive problems and positive deficit in the form of memory problems. The examiner stated that the neurological examination was as described and that the veteran appeared to be functioning quite well at this point. The examiner noted the veteran's mild cognitive deficit and some hemisensory loss, recommending he be followed up clinically. On a VA psychiatric examination in May 1999, it was noted that the veteran was employed for seven years with the post office. On mental status examination, he was casually dressed and cooperative. He was a man of average to above average intelligence without features of psychosis or major affective disturbance. There were no signs or symptoms of psychoneurological disturbances. His mental status was within normal limits, and he was without psychological complaints. He denied any depression. The veteran focused on two areas of stress in his life: (1) his frustration, anger, and resentment over having experienced the cerebrovascular accident (because he had planned to make a career out of the military) and his preoccupation with potential explanations for his cerebrovascular accident (he thought it might have been related to several inoculations in preparation for possible transfer to the area of Saudi Arabia at that time); and (2) work-related stress in that a co- worker was difficult to get along with, although the veteran liked his job and felt he was a good worker. The examiner summarized that there was no evidence of any co-morbid psychiatric disability at that time. There was no psychiatric diagnosis, and the veteran's GAF score was 81. II. Analysis Initially, it is noted that the veteran's claim for a higher rating is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is satisfied that all relevant evidence has been properly developed and that no further assistance is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The RO has rated the veteran's amnestic syndrome due to a brain stem event as 10 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8008 and 38 C.F.R. § 4.132, Diagnostic Code 9304. Under Code 8008, residuals of thrombosis of vessels of the brain are rated a minimum of 10 percent, provided that such residuals are objectively ascertainable. When ratings in excess of the prescribed 10 percent rating are assigned, the disability must be evaluated by analogy under the criteria of diagnostic codes relating to the impairment shown. 38 C.F.R. § 4.124a, Note. Purely neurological disabilities, such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, will be rated under the codes specifically dealing with such disabilities. Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under Code 9304; this 10 percent rating will not be combined with any other rating for a disability due to brain trauma, and ratings in excess of 10 percent for brain disease due to trauma under Code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The Board notes that the regulations pertaining to evaluating mental disorders were revised effective November 7, 1996, during the pendency of the present appeal. Under the circumstances of this case, either the old or new rating criteria may apply, whichever are most favorable to the veteran. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Under the old rating criteria, in effect prior to November 7, 1996, a 10 percent evaluation for dementia due to head trauma requires symptomatology which is less than the criteria required for the 30 percent evaluation, with emotional tension or other evidence of anxiety productive of mild social and industrial impairment. A 30 percent evaluation requires definite impairment in the ability to establish or maintain effective and wholesome relationships with people, where the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. (Definite impairment is construed to mean distinct, unambiguous and moderately large in degree. Op. G.C. Prec. 9-93 (November 9, 1993).) Higher evaluations are warranted for symptoms worse than the criteria for a 30 percent rating. 38 C.F.R. § 4.132, Diagnostic Code 9304 (1996). Under the new rating criteria, in effect since November 7, 1996, a 10 percent evaluation for dementia due to head trauma requires occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent evaluation requires occupational and social functioning with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Higher evaluations are warranted for symptoms worse than the criteria for a 30 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9304 (1999). The veteran contends that his service-connected disorder is more disabling than is reflected by his 10 percent rating. The RO in a February 1992 decision assigned the minimum 10 percent rating under Code 8045 on the basis of purely subjective complaints of dizziness, hypersomnia, and left- sided weakness (as stroke residuals) and no current psychiatric diagnosis. Subsequently, additional medical evidence was received showing a diagnosis of partial organic amnestic syndrome, and the RO continued the 10 percent rating on the basis of mild impairment of social and industrial adaptability under Code 9304. The Board finds that a different rating method, separately evaluating the brain stem event residuals (both neurological and psychiatric), will result in an overall higher rating. The medical evidence shows that the veteran has neurological manifestations due to the brain stem event suffered in service, and those manifestations involve the left upper extremity and left lower extremity. The medical evidence also shows that the veteran has psychiatric manifestations due to the brain stem event. The Board finds that these disabilities should be rated separately, as discussed below. Under 38 C.F.R. § 4.124a, Diagnostic Code 8518, which pertains to paralysis of the circumflex nerve, a 0 percent rating is warranted for mild incomplete paralysis of the circumflex nerve of the minor arm; a 10 percent rating is warranted when there is moderate incomplete paralysis. Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which pertains to paralysis of the sciatic nerve, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve of the leg; a 20 percent rating is warranted when there is moderate incomplete paralysis. Service medical records show that the veteran was weak on the left side following a brain stem event in May 1990. He showed gradual functional improvement and used a cane due to walking difficulties. By December 1990, the veteran's complaints included fatigue, poor attention span, positional vertigo, and brief episodes of diplopia. A psychiatric evaluation revealed a diagnosis of life-circumstance problem, and a neurological evaluation did not show any apparent deficit. Following service, VA examinations in 1991 show that the veteran complained of fatigability, hypersomnia, memory difficulty, dizzy spells with loss of balance, and pain and throbbing on the left side of his body. There was no diagnosis of a psychiatric disorder on a June 1991 VA examination, and VA neurological examinations were essentially normal in June 1991 and July 1991, despite the complaints. On a June 1991 VA orthopedic examination, the veteran was found to have no actual orthopedic disability other than complaints regarding the left lower extremity. On a July 1991 VA examination, the veteran had orthostatic dizziness (and not real vertigo causing dizziness), and his memory appeared to be good. On that examination, the veteran reported he had regained most of the function in his left upper and lower extremity but had occasional balance disturbance. Thereafter, his claims of memory loss persisted, and on VA neuropsychological evaluations in November 1991 and September 1992 clinical findings suggested dyslexia, a partial organic amnestic syndrome, and a depressive disorder. On an April 1993 VA examination, the veteran complained of headaches, light-headedness upon standing, memory difficulty, and left-sided numbness and throbbing; his diagnosis was amnestic syndrome from a cerebrovascular accident with a GAF score of 60 (to represent moderate symptoms or moderate difficulty in social and occupational functioning). On a March 1994 VA neurological examination, he was normal despite complaints of twitching in his face and some problems with his left leg. On a September 1997 VA psychiatric examination, he complained of dizzy spells, leg cramps, severe headaches, short term memory loss and difficulty learning new material, and decreased sleep; his diagnosis was amnestic disorder, not otherwise specified, with a GAF score of 61-70 (to represent mild symptoms or some difficulty in social and occupational functioning). On a May 1999 VA neurological examination, the veteran complained of fatigability and pain in the left lower extremity (particularly below the knees), weakness in the left upper extremity (more since recent left shoulder surgery), continued memory problems which did not significantly affect his job, monthly migraine headaches, and occasional dizzy spells related to light-headedness, nausea, and gait imbalance. The clinical findings were diplopia on the left, "give away" weakness in the left lower extremity (but he had a steady gait while walking), and decreased sensation to pin prick in patchy distribution on the left side. The diagnoses were probable left-sided hemiparesis and hemisensory deficit, cognitive problems, and memory problems, but the examiner stated that these findings were mild and that the veteran was functioning quite well. On a subsequent May 1999 VA psychiatric examination, there was no diagnosis of a psychiatric disorder, and the veteran's GAF score was 81 (to represent absent or minimal symptoms and good functioning in all areas). With regard to manifestations analogous to impairment of the circumflex and sciatic nerves, the clinical evidence shows that the veteran was essentially normal neurologically for many years after service but that currently he has some weakness in the left lower extremity and decreased sensation to pin prick in patchy distribution on the left side. These manifestations were evaluated as mild in degree, and the veteran could function quite well in spite of them. In light of this and also taking into consideration some left shoulder symptomatology from recent surgery (which has not been shown by the medical evidence to be related to the brain stem event in service), the Board finds that the left upper extremity symptomatology demonstrates no more than mild incomplete paralysis of the minor arm, and a noncompensable rating is warranted under Codes 8008 and 8518. Moreover, the Board finds that the left lower extremity symptomatology demonstrates mild incomplete paralysis of the leg, and hence a 10 percent rating is warranted under Codes 8008 and 8520. With regard to the psychiatric manifestations, the evidence shows that since service the veteran has been diagnosed (in November 1991, September 1992, and September 1997) with amnestic syndrome due to his brain stem event but that he had no psychiatric diagnosis on either a VA examination in June 1991 or his most recent VA examination in May 1999. The evidence also shows that his complaints of dizziness and memory problems have been persistent and that he has also reported headaches. Under Code 8045, no more than a 10 percent rating under Code 9304 for brain trauma is warranted for these subjective complaints. However, the veteran does not have "purely subjective complaints" under Code 8045 because he was shown to have cognitive and memory deficit on one of the May 1999 VA examinations (as well as on the evaluations in November 1991, September 1992, and September 1997). Therefore, such mental impairment is more appropriately evaluated as a residual of the brain stem event utilizing Code 9304. Applying either the old or new mental disorder regulations, the Board finds that the veteran's impairment is mild and does not meet the criteria for a rating in excess of 10 percent. For most of the years since service, the veteran has been employed at the post office, where he enjoys his job. His GAF scores largely reflect a mild degree of social and occupational impairment. There is no evidence of intermittent periods of inability to perform occupational tasks, depressed mood, suspiciousness, or panic attacks for a 30 percent rating. Hence, a 10 percent rating is warranted under Codes 8008 and 9304. At the present time, besides the left upper and lower extremity neurological problems and the psychiatric problems, no other compensable brain stem event residuals have been identified. The veteran is entitled to a separate 10 percent rating for the left lower extremity neurological residuals and a separate 10 percent rating for the psychiatric residuals. To this extent, an increase in the prior 10 percent rating is granted. ORDER To the extent that a 10 percent rating is assigned for left lower extremity neurological impairment and a 10 percent rating is assigned for psychiatric impairment, a higher rating for residuals of a brain stem event is granted. L. W. TOBIN Member, Board of Veterans' Appeals