Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024) (Cth)

Statement of Principles concerning CEREBROVASCULAR ACCIDENT (STROKE) (Reasonable Hypothesis) (No. 45 of 2024) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 21 June 2024.

Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority

Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions

1 Name This is the Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024). 2 Commencement This instrument commences on 23 July 2024. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning cerebrovascular accident No. 65 of 2015 (Federal Register of Legislation No. F2015L00652) made under subsections 196B(2) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about cerebrovascular accident (stroke) and death from cerebrovascular accident (stroke). Meaning of cerebrovascular accident (stroke) (2) For the purposes of this Statement of Principles, cerebrovascular accident (stroke): (a) means a sudden loss of brain function due to brain ischaemia or intracerebral haemorrhage; and (b) includes: (i) transient ischaemic attack; (ii) ischaemic stroke; and (iii) intracerebral haemorrhage; and (c) excludes: (i) subclinical or asymptomatic cerebrovascular disease identified by neuroimaging ("silent stroke"); (ii) subarachnoid haemorrhage; (iii) subdural haemorrhage; and (iv) extradural haemorrhage. Note: brain ischaemia and intracerebral haemorrhage are defined in the Schedule 1 - Dictionary. (3) While cerebrovascular accident (stroke) attracts ICD‑10‑AM codes I61, I63, I64, G45.0, G45.1, G45.2, G45.8, G45.9 or G46, in applying this Statement of Principles the meaning of cerebrovascular accident (stroke) is that given in subsection (2). (4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from cerebrovascular accident (stroke) (5) For the purposes of this Statement of Principles, cerebrovascular accident (stroke), in relation to a person, includes death from a terminal event or condition that was contributed to by the person's cerebrovascular accident (stroke). Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that cerebrovascular accident (stroke) and death from cerebrovascular accident (stroke) can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 9 Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting cerebrovascular accident (stroke) or death from cerebrovascular accident (stroke) with the circumstances of a person's relevant service: (1) having hypertension within the 10 years before clinical onset; (2) having a hypertensive emergency or crisis at the time of clinical onset; Note: hypertensive emergency or crisis is defined in the Schedule 1 - Dictionary. (3) inability to undertake any physical activity greater than three METs for at least 5 years within the 20 years before clinical onset; Note: MET is defined in the Schedule 1 - Dictionary. (4) consuming alcohol in an amount of at least 250 grams per week, for at least the 1 year before clinical onset; (5) for brain ischaemia only, binge drinking 300 grams of alcohol within the 7 days before clinical onset; (6) for intra-cerebral haemorrhage only, binge drinking: (a) 90 grams of alcohol within the 24 hours; or (b) 180 grams of alcohol within the 7 days; before clinical onset; (7) having one of the following brain infections within the 4 weeks before clinical onset: (a) cerebral abscess; (b) cerebral helminthic infection (cysticercosis, schistosomiasis, sparganosis); (c) cerebral malaria; (d) encephalitis; (e) infectious vasculitis; (f) intracerebral fungal infection (aspergillosis, coccidioidomycosis, Cryptococcus, histoplasmosis or mucormycosis); (g) meningitis (syphilis, tuberculosis, fungal, bacterial, viral); (h) neurosyphilis; or (i) tuberculosis; (8) having a Varicella-zoster virus infection, involving the brain, within the 1 year before clinical onset; (9) having infection with human immunodeficiency virus before clinical onset; (10) having one of the following systemic inflammatory disorders causing cerebral vasculitis at the time of clinical onset: (a) ankylosing spondylitis; (b) dermatomyositis; (c) inclusion body myositis; (d) polymyositis; (e) psoriatic arthritis; (f) rheumatoid arthritis; (g) systemic sclerosis (scleroderma); (h) Sjögren syndrome; or (i) systemic lupus erythematosus. (11) having gout at the time of clinical onset; (12) having one of the following vasculitides at the time of clinical onset: (a) antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis; (b) Behcet disease; (c) eosinophilic granulomatosis with polyangiitis (Churg Straus syndrome); (d) giant cell (temporal) arteritis; (e) granulomatosis with polyangiitis (Wegener granulomatosis); (f) Immunoglobulin A vasculitis (Henoch-Schönlein purpura); (g) microscopic polyangiitis; (h) neurosarcoidosis; (i) mucocutaneous lymph node syndrome (Kawasaki disease); (j) primary angiitis of the central nervous system; (k) polyarteritis nodosa; (l) Takayasu arteritis; or (m) thromboangiitis obliterans (Buerger disease); (13) having one of the following vessel disorders at the time of clinical onset: (a) atheroma of the penetrating arteries that arise from the vertebral artery, the basilar artery, the middle cerebral artery stem, and the arteries of the circle of Willis; (b) cerebral amyloid angiopathy; (c) cerebral arteriolosclerosis; (d) cerebral venous thrombosis; (e) Moyamoya disease or Moyamoya syndrome; (f) Susac syndrome (retinocochleocerebral vasculopathy); or (g) Sneddon syndrome; (14) having thrombotic thrombocytopaenic purpura, sickle cell disorder or vaccine-induced thrombotic thrombocytopaenia at the time of clinical onset; (15) being pregnant within the 6 weeks before clinical onset; (16) using one or more of the following drugs within the 72 hours before clinical onset: (a) amphetamines and amphetamine-type substances, excluding methylphenidate; (b) anabolic-androgenic steroids; (c) cocaine; (d) D-lysergic acid diethylamide (LSD); (e) opioids, including heroin; (f) marijuana; (g) phencyclidine (angel dust); (17) taking a selective serotonin reuptake inhibitor or another serotonergic drug for at least 2 weeks, within the 4 weeks before clinical onset; (18) taking an overdose of one or more serotonergic drugs, within the 4 weeks before clinical onset; (19) taking a non-topical, non-steroidal, anti-inflammatory drug, excluding aspirin, for a continuous period of at least 30 days before clinical onset, where the last dose of the drug was taken within the 7 days before clinical onset; Note: non-steroidal, anti-inflammatory drug is defined in the Schedule 1 - Dictionary. (20) having heat stroke at the time of clinical onset; Note: heat stroke is defined in the Schedule 1 - Dictionary. (21) being envenomated by a snake, scorpion, box jellyfish, bee, hornet or wasp within the 5 days before clinical onset; (22) having active migraine at the time of clinical onset; Note: active migraine is defined in the Schedule 1 - Dictionary. (23) having diabetes mellitus at the time of clinical onset; (24) having one of the following cardiac conditions with potential to give rise to a cerebral embolus within the 4 weeks before clinical onset: (a) a prosthetic mitral or aortic valve; (b) acute myocardial infarction; (c) atrial fibrillation and atrial flutter; (d) atrial septal aneurysm; (e) calcification of the mitral or aortic valve; (f) cardiac hydatid cysts; (g) cardiomyopathy; (h) congestive cardiac failure; (i) endocarditis; (j) ischaemic, valvular, arrhythmogenic and hypertensive cardiomyopathy; (k) Lambl excrescences of the mitral or aortic valve; (l) left atrial aneurysm or dilatation; (m) left ventricular aneurysm; (n) left ventricular dyskinesia; (o) mitral valve prolapse; (p) primary or secondary cardiac tumours; (q) regurgitation of the mitral or aortic valve; (r) rheumatic heart disease; (s) sick sinus syndrome; (t) stenosis of the mitral or aortic valve; (u) thrombus within the left atrium or left ventricle; or (v) valvulitis of the mitral or aortic valve; (25) having one of the following non-cardiac causes of cerebral arterial embolism at the time of the clinical onset: (a) aortic arch atherosclerosis; (b) decompression sickness; (c) endoscopic retrograde cholangiopancreatography; (d) pulmonary barotrauma; (e) severe bone trauma; (f) thrombus formation within the pulmonary vein, or arteries supplying the affected area of the brain; (26) having a deep vein thrombosis or venous air embolism with one of the following anatomical defects at the time of clinical onset: (a) atrial septal defect; (b) patent foramen ovale; (c) pulmonary arteriovenous fistula; or (d) ventricular septal defect. Note: Examples of circumstances where venous air embolism may occur include air bubble echocardiogram, sclerotherapy for varicose veins or removal of a central venous catheter. (27) undergoing one of the following procedures within the 4 weeks before clinical onset: (a) cardiac surgery or cardiac catheterisation; (b) catheterisation of or injection into the arteries supplying the brain; (c) major surgical procedure involving general or regional anaesthesia, including orthopaedic surgery or neurosurgery; or (d) surgery involving the arteries supplying the brain, including carotid endarterectomy; (28) having septicaemia or an infection requiring admission to hospital within the 3 months before clinical onset; (29) having an injury or illness requiring admission to an intensive care unit or artificial ventilation, within the 3 months before clinical onset; (30) having a malignant neoplasm, excluding non-melanotic malignant neoplasm of the skin, within the 1 year before clinical onset; (31) having cirrhosis of the liver or chronic liver disease at the time of clinical onset; (32) having chronic kidney disease before clinical onset; Note: chronic kidney disease is defined in the Schedule 1 – Dictionary. (33) experiencing a moderate to severe traumatic brain injury within the 1 year before clinical onset; (34) being obese for at least 5 years within the 15 years before clinical onset; Note: being obese is defined in the Schedule 1 – Dictionary. (35) for males, having a waist to hip circumference ratio exceeding 1.0 for at least 5 years within the 15 years before clinical onset; (36) for females, having a waist to hip circumference ratio exceeding 0.9 for at least 5 years within the 15 years before clinical onset; (37) for intracerebral haemorrhage only, being underweight for at least 5 years within the 10 years before clinical onset; Note: being underweight is defined in the Schedule 1 - Dictionary. (38) having symptomatic inflammatory bowel disease within the ten years before clinical onset; (39) having clinically significant depressive disorder within the 2 years before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (40) experiencing a category 1A stressor within the 4 weeks before clinical onset; Note: category 1A stressor is defined in the Schedule 1 – Dictionary. (41) experiencing a category 1B stressor within the 4 weeks before clinical onset; Note: category 1B stressor is defined in the Schedule 1 – Dictionary. (42) experiencing a category 2 stressor within the one year before clinical onset; Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation. Note 2: category 2 stressor is defined in the Schedule 1 - Dictionary. (43) having panic disorder at the time of clinical onset; (44) having phobic anxiety with panic attack at the time of clinical onset; (45) having clinically significant posttraumatic stress disorder within the 1 year before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (46) having clinically significant adjustment disorder within the 1 year before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (47) having clinically significant anxiety disorder within the 1 year before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (48) having clinically significant schizophrenia within the 1 year before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (49) having clinically significant bipolar disorder within 1 year before clinical onset; Note: clinically significant is defined in the Schedule 1 – Dictionary. (50) having periodontitis for at least the 2 years before clinical onset; (51) an inability to consume an average of at least 100 grams per day of vegetables or fruits, for at least the 1 year before clinical onset; (52) consuming an average daily intake of at least 12 grams (200 millimoles) per day of salt (sodium chloride) for at least the 6 months before clinical onset; (53) having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the 3 months before clinical onset; Note: SARS-CoV-2 is the virus which causes coronavirus disease 2019 (COVID-19). (54) for brain ischaemia only, where smoking has not ceased before clinical onset: (a) smoking an average of at least 1 cigarette per day, or the equivalent thereof in other tobacco products, for at least the one year before clinical onset; or (b) smoking at least one half of one pack-year before clinical onset; Note: one pack-year is defined in the Schedule 1 - Dictionary. (55) for intracerebral haemorrhage only, where smoking has not ceased before clinical onset: (a) smoking an average of at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, for at least the 1 year before clinical onset; or (b) smoking at least one pack-year before clinical onset; Note: one pack-year is defined in the Schedule 1 - Dictionary. (56) for brain ischaemia only, where smoking has ceased before clinical onset: (a) smoking at least one pack-year but less than 5 pack-years, before clinical onset, and clinical onset has occurred within 10 years of smoking cessation; or (b) smoking at least 5 pack-years but less than 10 pack-years, before clinical onset, and clinical onset occurred within 20 years of smoking cessation; or (c) smoking at least 10 pack-years before clinical onset; Note: one pack-year is defined in the Schedule 1 - Dictionary. (57) for intracerebral haemorrhage only, where smoking has ceased before the clinical onset of cerebrovascular accident: (a) smoking at least one pack-year but less than 10 pack-years before the clinical onset of cerebrovascular accident, and the clinical onset of cerebrovascular accident has occurred within 10 years of smoking cessation; or (b) smoking at least 10 pack-years before clinical onset, and the clinical onset occurred within 20 years of smoking cessation; Note: one pack-year is defined in the Schedule 1 - Dictionary. (58) having been exposed to second-hand smoke: (a) for at least 5,000 hours before clinical onset; and (b) where the last exposure to second-hand smoke occurred within the 5 years before clinical onset; Note: exposed to second-hand smoke is defined in the Schedule 1 – Dictionary. (59) for brain ischaemia only, having dyslipidaemia within the 20 years before clinical onset; Note: dyslipidaemia is defined in the Schedule 1 - Dictionary. (60) having an upper respiratory tract infection, including sinusitis, within the 4 weeks before clinical onset; (61) for brain ischaemia only, being treated with intravenous immunoglobulin within the 72 hours before clinical onset; (62) for brain ischaemia only, taking combined oral or non-oral estrogen-progestogen contraception for a continuous period of at least 21 days, within the 4 weeks before clinical onset; (63) for brain ischaemia only, taking hormone replacement therapy for a continuous period of at least 21 days within the 5 years before clinical onset; Note: hormone replacement therapy is defined in the Schedule 1 - Dictionary. (64) for brain ischaemia only, taking tamoxifen for a continuous period of at least the 21 days before clinical onset; (65) for brain ischaemia only, having carotid artery disease, or occlusion or stenosis of the vertebral artery, basilar artery, aortic arch or ascending aorta due to atherosclerosis, fibromuscular dysplasia, dissection or other pathological process involving that artery, at the time of clinical onset; (66) for brain ischaemia only, having a subarachnoid haemorrhage within the 2 weeks before clinical onset; (67) for brain ischaemia only, having one of the following hypercoagulable states at the time of the clinical onset: (a) acquired activated protein C resistance; (b) acquired antithrombin III deficiency; (c) acquired dysfibrinogenaemia; (d) acquired protein C deficiency; (e) acquired protein S deficiency; (f) antiphospholipid antibody syndrome; (g) aplastic anaemia; (h) disseminated intravascular coagulation; (i) haemolytic uraemic syndrome; (j) heparin-induced thrombocytopaenia; (k) hyperfibrinogenaemia; (l) hyperproteinaemia; (m) hyperviscosity syndrome; (n) chronic idiopathic thrombocytopaenic purpura or immune thrombocytopaenia; (o) myeloma; (p) myeloproliferative disease; (q) nephrotic syndrome; (r) paroxysmal nocturnal haemoglobinuria; or (s) thrombocytosis; (68) for brain ischaemia only, experiencing an acute hypotensive episode within the 24 hours before clinical onset; Note: acute hypotensive episode is defined in the Schedule 1 - Dictionary. (69) having sleep apnoea at the time of clinical onset; (70) undergoing a course of therapeutic radiation for cancer, where the head, neck or mediastinum was in the field of radiation, before clinical onset; (71) having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the head, neck or mediastinum before clinical onset; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. (72) for brain ischaemia only, having hyperhomocysteinaemia at the time of clinical onset; (73) for brain ischaemia only, having one of the following traumatic injuries to the neck or the base of the skull within the 4 weeks before clinical onset: (a) a non-penetrating injury, involving extension, rotation, hyperflexion or compression of the neck; (b) an injury resulting in fracture or dislocation of the cervical spine; (c) a penetrating injury to the neck or the base of the skull; (d) foreign body penetration or blunt injury of an artery within the head, neck or chest; (74) for brain ischaemia only, inhaling polluted air, for a cumulative period of at least 100 hours, within the 7 days before clinical onset; Note: polluted air is defined in the Schedule 1 – Dictionary. (75) inhaling chronically polluted air for at least 1000 hours, within the 5 years before clinical onset; Note: chronically polluted air is defined in the Schedule 1 – Dictionary. (76) for intracerebral haemorrhage only, undergoing anticoagulant therapy within the 30 days before clinical onset; Note: anticoagulant therapy is defined in the Schedule 1 – Dictionary. (77) for intracerebral haemorrhage only, taking one of the following antiplatelet drugs on at least 3 days per week for a continuous period of at least 4 weeks before clinical onset, where the last dose was taken no more than 30 days before clinical onset: (a) aspirin; (b) clopidogrel; (c) prasugrel; (d) ticagrelor; (e) dipyridamole; or (f) ticlopidine; (78) for intracerebral haemorrhage only, undergoing thrombolytic (fibrinolytic) therapy within the 7 days before clinical onset; Note: thrombolytic (fibrinolytic) therapy is defined in the Schedule 1 - Dictionary. (79) for intracerebral haemorrhage only, having one of the following disorders at the time of clinical onset: (a) aplastic anaemia; (b) idiopathic thrombocytopaenic purpura or immune thrombocytopaenia; (c) disseminated intravascular coagulation; (d) essential thrombocythaemia; (e) Hodgkin lymphoma; (f) inherited or acquired coagulation protein disorder, including haemophilia; (g) leukaemia; (h) myeloma; (i) non-Hodgkin lymphoma; (j) post-transfusion purpura; (k) qualitative platelet defects associated with coagulation defect; (l) thrombocytopaenia; or (m) vitamin K deficiency; (80) for intracerebral haemorrhage only, bleeding of one of the following intracerebral space occupying lesions at the time of clinical onset: (a) abscess; (b) cyst; (c) neoplasm; or (d) tuberculoma; (81) for intracerebral haemorrhage only, bleeding from a cerebral aneurysm or a cerebral vascular malformation at the time of clinical onset; (82) being sedentary for a cumulative total of at least 10 hours per day on more days than not for at least the 5 years before clinical onset; Note: being sedentary is defined in the Schedule 1 - Dictionary. (83) taking one of the following anti-androgen medications for at least the 6 months before clinical onset: (a) androgen receptor blockers, including cyproterone acetate, flutamide and bicalutamide; (b) gonadotrophin releasing hormone agonists, including goserelin and leuprorelin; or (c) gonadotrophin releasing hormone antagonists, including degarelix; (84) having bilateral orchiectomy before clinical onset; (85) for brain ischaemia only, having compression of the carotid, vertebral, basilar or cerebral artery at the time of clinical onset; Note: Examples of a mass or structure that can cause compression include osteophytes associated with cervical spondylosis (especially with rotation of the neck beyond 45 degrees), an abscess, haematoma or neoplasm in the neck. (86) taking an antipsychotic drug on more days than not for at least one week, within the 6 months before clinical onset; (87) taking tibolone for a continuous period of at least 21 days within the 2 months before clinical onset; (88) taking a systemic vascular endothelial growth factor (VEGF) inhibitor or monthly intra-vitreous injections of a VEGF inhibitor within the 4 months before clinical; Note: Vascular endothelial growth factor (VEGF) inhibitors include monoclonal antibodies, such as bevacizumab; fusion molecules such as aflibercept; and tyrosine kinase inhibitors, such as axitinib, cabozantinib, lenvatinib, nintedanib, pazopanib, sorafenib, sunitinib and vandetanib. Systemic VEGF inhibitors are used in the treatment of several cancers, and other indications such as interstitial lung disease. Intra-vitreous injections of VEGF inhibitors (such as aflibercept, bevacizumab, ranibizumab) are used mostly in the treatment of age-related macular degeneration, macular oedema due to diabetes mellitus or retinal vein occlusion and choroidal neovascularisation. (89) taking alemtuzumab within the 30 days before clinical onset; Note: Alemtuzumab is usually used for treatment of multiple sclerosis or chronic lymphocytic leukaemia. (90) taking ponatinib on more days than not for 2 weeks within the 30 days before clinical onset; Note: Ponatinib is usually used for treatment of chronic myeloid leukaemia or acute lymphoblastic leukaemia. (91) taking a thalidomide analogue within the 30 days before clinical onset; Note: a thalidomide analogue includes thalidomide, lenalidomide and pomalidomide and are used in the treatment of multiple myeloma, myelodysplastic syndrome, mantle cell lymphoma and erythema nodosum leprosum. (92) inability to obtain appropriate clinical management for cerebrovascular accident (stroke) prior to clinical worsening.