Diagnostic ultrasound for rotational vertebral artery syndrome: indications, examination technique, diagnostic criteria, and algorithm (Russian expert consensus)

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Abstract

This article presents a consensus statement by Russian experts dedicated to the ultrasound diagnosis of rotational vertebral artery syndrome. Rotational extravascular compression of the vertebral artery is reported in 5%–17% of cases. In turn, it represents a substantial cause of vertebrobasilar insufficiency; however, it may also be asymptomatic. Clinical signs of rotational vertebral artery syndrome are non-specific but are invariably associated with changes in head position and rapidly regress after return to the neutral position. The risk of developing clinical symptoms increases when the dominant vertebral artery is compressed. The most common level of compression is the third (V3) segment in young and middle-aged patients and the second (V2) segment in older individuals. The causes of rotational vertebral artery syndrome include congenital anomalies and acquired skeletal deformities, hypertrophy or spasm of the cervical muscles, and external compression by various space-occupying lesions of the neck.

The absence of unified standards and insufficient awareness among clinicians regarding the clinical signs and diagnostic approaches for rotational vertebral artery syndrome often result in overdiagnosis of this medical condition.

The paper describes the ultrasound examination technique using rotational head and neck maneuvers (including the arteries assessed, transducers employed, patient and examiner positioning, and types of head and neck rotation). Topographic and anatomical limitations of visualizing arteries of the vertebrobasilar circulation depending on head rotation are discussed, along with criteria for interpreting the results (including pre-compression, compression, and post-compression blood flow changes). In addition, a diagnostic algorithm is presented, outlining key elements that should be included in the examination report, as well as a clinical case example. The authors emphasize the importance of the follow-up hemodynamic assessment of segments of the vertebral artery, basilar artery, or posterior cerebral arteries to identify the level and regional significance of the compression. The proposed algorithm enables standardization of diagnostic approaches and reduces the risk of errors in clinical practice.

About the authors

Andrey O. Chechetkin

Russian Сenter of Neurology and Neurosciences

Author for correspondence.
Email: andreychechetkin@gmail.com
ORCID iD: 0000-0002-8726-8928
SPIN-code: 9394-6995

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

Tatyana V. Balakhonova

National Medical Research Centre of Cardiology named after Academician E.I. Chazov

Email: tvbdoc@gmail.com
ORCID iD: 0000-0002-7273-6979
SPIN-code: 3738-3289

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow

Tatiana N. Enkina

North-Western District and Scientific Clinical Center named after L.G. Sokolov

Email: tatiana.enkina@yandex.ru
ORCID iD: 0009-0004-7739-1684
SPIN-code: 7594-1380

MD, Cand. Sci. (Medicine)

Russian Federation, Saint Petersburg

Vladimir P. Kulikov

Altai State Medical University

Email: kulikov57@mail.ru
ORCID iD: 0000-0003-4869-5465
SPIN-code: 9224-1959

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Barnaul

Irina E. Timina

A.V. Vishnevsky National Medical Research Center of Surgery

Email: timina68@mail.ru
ORCID iD: 0000-0001-7026-9417
SPIN-code: 1100-8854

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

Ludmila E. Shulgina

Polyclinic No. 1 of the Presidential Administration of the Russian Federation

Email: ofd-shulgina@yandex.ru
ORCID iD: 0009-0009-6325-8766
SPIN-code: 7757-2071

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

Margarita V. Shumilina

National Medical Research Center for Cardiovascular Surgery named after A.N. Bakulev

Email: Shumilinamv@yandex.ru
ORCID iD: 0000-0001-9871-8173
SPIN-code: 8102-9042

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

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2. Fig. 1. Head positions during ultrasound examination of the vertebral arteries with rotational tests: a — rotation to the right with extension; b — extension; c — left rotation with extension; d — right rotation; e — neutral position; f — left rotation; g — right rotation with flexion; h — flexion; i — left rotation with flexion. "+" — optimal visualisation; "+/−" — limited visualisation; "−" — visualisation impossible. V1 — first segment of the vertebral artery; V2 — second segment of the vertebral artery; V3 — third segment of the vertebral artery.

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3. Fig. 2. Patterns of prestenotic (a), stenotic (b), poststenotic (c) blood flow, and preocclusion blood flow (d).

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4. Fig. 3. Diagram of the algorithm for conducting an ultrasound examination with rotational samples.

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5. Fig. 4. Recording of blood flow in the arteries of the vertebral-basilar basin in a patient with functional compression of the left vertebral artery in the V3 segment. Recording of blood flow in the left vertebral artery: a — in the V2 segment with the head in a neutral position; b — in the V2 segment with the head turned to the right; c — in the V2 segment with the head turned to the right with extension; d — in the V3 segment with the head in a neutral position; e — in the V3 segment with the head turned to the right; f — in the V3 segment with the head turned to the right with extension. Registration of blood flow in the right vertebral artery: g — in the V1 segment with the head in a neutral position; h — in the V1 segment with the head turned to the right with extension. Blood flow recording in the left posterior cerebral artery: i — in the P1 segment with the head in a neutral position; j — in the P1 segment when turning the head to the right with extension; k — in the P2 segment with the head in a neutral position; l — in the P2 segment when turning the head to the right with extension; m — a 2-fold increase in blood flow velocity in the P1 segment during compression of the ipsilateral common carotid artery (the yellow arrow indicates the moment of compression). PPS — peak systolic velocity; IR — resistance index; LBA — left posterior cerebral artery.

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6. Fig. 5. Results of functional angiography (a) of the left vertebral artery and computed tomography (b) of the cervical spine: a — subtotal stenosis of the vertebral artery lumen above the second cervical vertebra (the site of compression is indicated by an arrow) when turning the head to the left with simultaneous extension; b — rotational subluxation of the second cervical vertebra (indicated by a dotted square).

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