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

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.