Computed Tomography Evaluation of Frontal Sinus Volume in Migraine Patients.

This study aimed to assess the frontal sinus volume (FSV) on computed tomography (CT) scans in migraine patients. Cranial and paranasal CT images from 75 migraine patients (mean age: 39.14±13.63 y) and 23 control cases (mean age: 38.78±13.32 y) were analyzed retrospectively. Three-dimensionally reconstructed images of frontal sinuses were generated. Total FSV, anterolateral, and transverse diameters of the head were measured. The presence/absence and nature of supraorbital foramen and notches were evaluated. The total FSV was 8.02±5.97 cm 3 in the migraine group and 8.38±4.83 cm 3 in the control group, with no significant differences between them. Mean FSV values showed no statistically significant difference between females (7.79±5.85 cm 3 ) and males (9.12±6.66 cm 3 ) within and between the groups. Single notch was the most observed structure in both groups, with bilateral presence being the most common. Double foramen and notch were observed only in the migraine group, and the coexistence of both structures was higher in the migraine patients than in controls. There was no statistical difference in FSV between migraine and control groups, nor based on sex. Overall, the frontal region anatomy, particularly the exit locations of the supraorbital or supratrochlear foramen/notches, may be influenced by hyperplasia/hypoplasia of FSV. Therefore, assessing FSV using CT may be crucial for surgical planning in migraine patients undergoing open or endoscopic approaches to the frontal region.

The place of B-mode ultrasonography, shear-wave elastography, and superb microvascular imaging in the diagnosis of De Quervain tenosynovitis.

PURPOSE: Superb microvascular imaging (SMI) and Shear wave elastography (SWE) are newly developed ultrasonographic diagnostic tools used to support the diagnosis of De Quervain tenosynovitis (DQT). The aim of this study was to examine the capacity to differentiate between the wrist with DQT and the healthy wrist, as well as the potential for predicting the disease's severity using B-mode ultrasonography, SWE, and SMI. METHODS: A total of 19 cases with unilateral clinical DQT were included in the prospective study. The wrists of these cases without DQT clinic constituted the control group. RESULTS: The SWE parameters of m/s and kPa cutoff values were ≤5.225 and ≤ 77.65, respectively, in the wrists with DQT compared to the wrists not diagnosed with DQT (p < 0.001). Regarding SMI findings no microvascularity was determined in the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon sheaths of the wrists without DQT, and a significant increase was observed in the degree of microvascularity as the clinical severity of DQT increased. CONCLUSION: SWE results can differentiate between the presence and absence of DQT. SMI grading of the APL and EPB tendon sheaths may be helpful to the clinician in deciding the clinical severity of DQT.

Pterygospinous and pterygoalar bars in children.

PURPOSE: The formation of pterygoalar (Pa) and pterygospinous (Ps) bars are controversial whether they are secondary ossifications with aging or phylogenetic remnant. Therefore we aimed to evaluate the presence of Pa and Ps bars in children on routine cranial computed tomography images. METHODS: We retrospectively analyzed the cranial computed tomography images of 500 children under the age of 18. Besides the 0.5 mm axial images, maximum intensity projection and 3D reconstructions were also used. The existence of incomplete or complete Pa and Ps bars were investigated. RESULTS: Incomplete and complete Pa bar was detected in 4.6% and 2.2% of the cases, respectively. Incomplete Ps bar was seen in 13.6% of the cases and complete was in 6%. In total, per 1000 sides, 12 (2.4%) complete and 27 (5.4%) incomplete Pa bars were detected. In the same way, 35 (7%) complete and 88 (17.6%) incomplete Ps bars were seen. The smallest age ossification detected was 5 months old. Additionally, the prevalence of Pa and Ps bars between the under and over 10 years old age groups were statistically significant. Aging increased the prevalence. CONCLUSION: Considering our results, it seems that the ossification of Pa and Ps ligaments may not be solely related with aging.

Anatomic features of the cranial aperture of the optic canal in children: a radiologic study.

OBJECTIVE: This study aimed to peruse anatomic features of the cranial aperture of the optic canal (CAOC) for obtaining an extended morphometric dataset in children. METHODS: Computed tomography images of 200 children were included in this retrospective work to analyze the shape, location and diameters of the CAOC. RESULTS: The CAOC area, width and height were observed as 17.53 ± 2.80 mm2, 6.12 ± 0.84 mm, and 4.35 ± 0.64 mm, respectively. The angle of the optic canal in axial plane was found as 39.28 ± 5.13°, while in sagittal plane as 16.01 ± 6.76°. The distance between the CAOC and the midsagittal line was 7.17 ± 1.48 mm. The CAOC was measured as 54.04 ± 5.23 mm and 42.55 ± 3.28 mm away from the anterior and lateral boundary of the anterior skull base, respectively. The CAOC shape was described as the tear-drop (186 foramina, 46.5%), triangular (156 foramina, 39%), oval (47 foramina, 11.8%), and round (11 foramina, 2.8%). CONCLUSION: The depth, angle and diameter measurements belonging to the CAOC were changing according to its shape or demographic data (e.g., sex and age). Therefore, preoperative radiologic evaluation containing the shape, location and size of the CAOC should be considered by multidisciplinary operating teams in terms of surgical interventions such as implant positioning.

Anatomic Variations of Paranasal Region in Migraine.

PURPOSE: To assess the incidence of anatomical variations of the paranasal region on computed tomography in migraine patients compared with control subjects. METHODS: Paranasal computed tomography scans of 2 groups consisting of 50 migraine patients and 50 control subjects were evaluated, retrospectively. The presence of anatomic variations and the unilateral or bilateral presence of these variations were noted. Appropriate statistical tests were performed to compare the migraine and control groups, using a threshold P value of 0.05 for statistical significance. RESULTS: The migraine group included 39 female and 11 male patients with mean age of 39.9 (range: 18-65) years. The control subject group included 29 female and 21 male patients with mean age of 41.9 (range: 18-73) years. Anatomic variations noted included nasal septal deviation and spur, paradoxical curvature of middle concha, agger nasi cell, infraorbital ethmoidal (Haller) cells, sphenoethmoidal (Onodi) cells, supraorbital ethmoidal air cells, concha bullosa, uncinate bulla, and pneumatized crista galli. Of these variations, only the presence of Haller cells was statistically significantly higher in the migraine group compared with controls (P = 0.007). The unilateral presence of Onodi (P < 0.001), unilateral presence of supraorbital ethmoidal air cells (P = 0.012), and bilateral presence of concha bullosa (P = 0.016) were statistically significantly higher in the migraine group. There was no statistically significant difference between the unilateral or bilateral presence of Haller cells in migraine patients compared with controls (P > 0.05). CONCLUSION: Radiographic assessment of the paranasal sinuses is useful to elucidate potential points of pathology in migraine patients. The specific contribution of Haller cells to migraine headache symptoms and safe methods for surgical decompression warrant further study.

Radiologic Evaluation of Exiting Points of Supraorbital Region Neurovascular Bundles in Patients With Migraine.

PURPOSE: To reveal the presence and nature of exiting points of supraorbital region neurovascular structures and determine the distances of those structures to midline with computed tomography images by taking into account gender and sides in patients with migraine. METHODS: The study was conducted retrospectively on computed tomography images of 70 migraine and 70 control patients with a mean age of 39.5 ±â€Š13.8 years (range: 18-80). Presence and nature (foramen or notch) of exiting points of neurovascular structures in terms of side and gender in both groups, and the distances of these structures to the midline of the face were evaluated. RESULTS: In migraine and control groups, the most commonly seen structure was single notch. Coexistence of foramen and notch was statistically significant in migraine and female migraine groups than control and female control groups (P < 0.05). Bilateral presence of supraorbital structure was 51.4% in migraine group and 64.3% in control group patients. In all cases, foramen-midline distance was statistically significant longer than the notch-midline distance (P < 0.05). In migraine patients, no statistically significant difference was detected regarding distances of foramen and notch to midline in terms of side and gender. CONCLUSION: Consideration of variable presence and location of the supraorbital notch and foramen, analysis of computed tomography scan might be beneficial in preoperative planning of foraminotomy and fascial band release in adult migraine patients to prevent intraoperative complications. Also, coexistence is more frequent on left side in migraine patients that might cause overlooking those structures during surgery.

A Rare Cause of Recurrent Cerebral Ischemia and Syncope: Eagle Syndrome.

Eagle syndrome is defined as symptomatic elongation of the styloid process or calcification of the stylohyoid and stilomandibular ligament. The syndrome was described by WW Eagle in 1937. The styloid process is located between the internal and external carotid arteries and laterally in the tonsillar fossa. Patients with cerebrovascular ischemia causing syncope or hemiparesia due to Eagle syndrome are rarely published in the literature. The authors presented a patient with recurrent cerebrovascular attacks due to long styloid process.

Stent-Assisted Coil Embolization of Posttraumatic Dissecting Carotid Aneurysm Causing Ophthalmoplegia.

BACKGROUND: Ophthalmoplegia secondary to a traumatic dissecting aneurysm in the cavernous segment of internal carotid artery (ICA) is a relatively rare entity. Anticoagulant or antiplatelet therapy is the preferred treatment option for carotid dissections. However, endovascular interventions are noninvasive and alternative methods to surgery, especially in cases of aneurysms that do not respond to medical therapy. CASE REPORT: We report of a 19-year-old man presenting with left-sided, total ophthalmoplegia after a traffic accident. Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) revealed a dissection beginning at the cervical segment of internal carotid artery (ICA) together with a dissecting aneurysm in the cavernous segment. A stent was placed in the narrowed and dissected segment of ICA, and the dissecting aneurysm of the cavernous segment was successfully managed with a stent-assisted coil embolization. After the endovascular treatment of the aneurysm, a full recovery of cranial nerve function was achieved. CONCLUSIONS: Immediate diagnosis and appropriate therapy of dissecting aneurysms is necessary for good clinical outcomes in cases of ophthalmoplegia.

Diabetic striatopathy in a patient with hemiballism.

Diabetic striatopathy is a rare and life-threatening manifestation of diabetes mellitus. The disease commonly affects individuals of Asian descent, females, and the elderly. Patients usually present with hemiballism-hemichorea caused by nonketotic hyperglycemia. Hemiballism-hemichorea is defined as involuntary continuous random appearing movement involving one side of the body. This movement disorder may develop secondary to stroke, diabetic striatopathy, neoplasm, infection, Wilson's disease, and thyrotoxicosis. Despite being rare, prompt recognition of a hyperglycemia-induced hemiballism-hemichorea is essential because the symptoms are reversible with correction of hyperglycemia. Diagnosis is possible based on blood analysis and neuroimaging findings. Laboratory tests reveal raised blood glucose and hemoglobin A1C levels which indicate poorly controlled diabetes. Neuroimaging provides suggestive findings of diabetic striatopathy which are hyperattenuation on computed tomography and hyperintensity on T1-weighted magnetic resonance imaging in the basal ganglia. In this case report, our aim is to present neuroimaging findings in an adult man with sudden onset of hemiballism associated with nonketotic hyperglycemia.

The diagnostic value of chest X-ray scanning by the help of Artificial Intelligence in Heart Failure (ART-IN-HF).

BACKGROUND: Typical signs of heart failure (HF), like increased cardiothoracic ratio (CTR) and pleural effusion, can be seen on X-ray. Artificial Intelligence (AI) can help in the early and quicker diagnosis of HF. OBJECTIVES: The study's goal was to demonstrate that the AI interpretation of chest X-rays can assist the clinician in diagnosing HF. METHODS: Patients older than 45 years were included in the study. The study analyzed 10 100 deidentified outpatient chest X-rays by AI algorithm. The AI-generated report was later verified by an independent radiologist. Patients with CTR > 0.5 and pleural effusion were marked as potential HF. Flagged patients underwent confirmatory tests, and those labeled as negative also underwent further investigations to rule out HF. RESULTS: Out of 10 100, the AI algorithm detected 183 (1.8%) patients with increased CTR and pleural effusion on chest X-rays. One hundred and six out of 183 underwent diagnostic tests. Eighty-two (77%) out of 106 were diagnosed with HF according to current guidelines. From the remaining 9917 patients, 106 patients were randomly selected. Nine (8%) out of them were diagnosed with HF. The positive predictive value of AI for diagnosing HF is 77%, and the negative predictive value is 91%. More than half (54.9%) of newly diagnosed patients had HF with preserved ejection fraction. CONCLUSION: HF is a risky condition with nonspecific symptoms that are difficult to diagnose, especially in the early stages. Using AI assistance for X-ray interpretation can be helpful for early diagnosis of HF especially HF with preserved ejection fraction.

Evaluation of abdominal computed tomography findings in patients with COVID-19: a multicenter study

PURPOSE: To evaluate the frequency of abdominal computed tomography (CT) findings in patients with coronavirus disease-2019 (COVID-19) and interrogate the relationship between abdominal CT findings and patient demographic features, clinical findings, and laboratory test results as well as the CT atherosclerosis score in the abdominal aorta. METHODS: This study was designed as a multicenter retrospective study. The abdominal CT findings of 1.181 patients with positive abdominal symptoms from 26 tertiary medical centers with a positive polymerase chain-reaction test for severe acute respiratory syndrome coronavirus 2 were reviewed. The frequency of ischemic and non-ischemic CT findings as well as the association between CT findings, clinical features, and abdominal aortic calcific atherosclerosis score (AA-CAS) were recorded. RESULTS: Ischemic and non-ischemic abdominal CT findings were detected in 240 (20.3%) and 328 (27.7%) patients, respectively. In 147 patients (12.4%), intra-abdominal malignancy was present. The most frequent ischemic abdominal CT findings were bowel wall thickening (n = 120; 10.2%) and perivascular infiltration (n = 40; 3.4%). As for non-ischemic findings, colitis (n = 91; 7.7%) and small bowel inflammation (n = 73; 6.2%) constituted the most frequent disease processes. The duration of hospital stay was found to be higher in patients with abdominal CT findings than in patients without any positive findings (13.8 ± 13 vs. 10.4 ± 12.8 days, P < 0.001). The frequency of abdominal CT findings was significantly higher in patients who did not survive the infection than in patients who were discharged after recovery (41.7% vs. 27.4%, P < 0.001). Increased AA-CAS was found to be associated with a higher risk of ischemic conditions in abdominal CT examinations. CONCLUSION: Abdominal symptoms in patients with COVID-19 are usually associated with positive CT findings. The presence of ischemic findings on CT correlates with poor COVID-19 outcomes. A high AA-CAS is associated with abdominal ischemic findings in patients with COVID-19.

The place of B-mode ultrasonography, shear-wave elastography, and superb microvascular imaging in the pre-diagnosis of androgenetic alopecia.

PURPOSE: Androgenetic alopecia (AGA) is the most common cause of hair loss in males. Physical examination and history are the most important examinations in diagnosis of the disease. As yet, there is no diagnostic method to be able to determine which individuals will develop AGA. Shear-wave elastography (SWE) is a novel diagnostic tool, which can evaluate tissue stiffness. Superb microvascular imaging (SMI) can determine low flow in microvessels. The aim of the current study was to determine whether or not AGA would develop in individuals with normal hair and a family history of AGA using B-mode US, SMI, and SWE. METHODS: The study included 26 patients clinically diagnosed with AGA and a control group of 26 volunteers. RESULTS: Thickness with the distance from the epidermis to the calvarium (ECD) on the hairline and cranial subcutaneous tissue thickness (CSTD) were determined to be statistically significantly thinner in the AGA group than in the control group (p < 0.0001). For the differentiation of the AGA patients, the cutoff value was determined to be 5.5 mm for ECD and 4.05 mm for CSTD. The cranial epidermis-dermis (CED) stiffness values both as meter/second (m/s) and kilopascals (kPa) were statistically significantly lower in the AGA patients than in the control group (p < 0.0001). The cutoff values were 6.075 as m/s and 104.4 as kPa. CONCLUSIONS: The results of this study demonstrated that differentiation could be made of individuals before the development of AGA from normal healthy individuals with CSTD measurement on B-mode US and CED stiffness measurement on SWE.

Evaluation of facial artery course variations and depth by Doppler ultrasonography.

BACKGROUND: As deep nasolabial folds (NLF) are associated with facial aging, there is an increasing demand for esthetic correction with filler injections. Understanding the anatomy of the angular artery (AA) and facial artery (FA) around the NLF region is essential for ensuring the safety of dermal filler injections into the NLF. The purpose of this study was to provide detailed vascular anatomical information on the course and depth of AA and FA around NLF using Doppler ultrasound on live cases. METHODS: FA was observed from the origin level adjacent to the mandible corpus to the end of its terminal branch AA in 168 hemifaces of 84 cases with Doppler ultrasonography. RESULTS: We made a classification of the FA course based on the NLF. The minimum and maximum depths of the FA along its course were measured in 84 cases. The results showed that its course may be highly superficial (2.5 mm at the mandibular origin, 3.7 mm at the cheilion, 3.7 mm at the nasal ala) or it may follow a very deep course near the periosteum (15.0 mm at the mandibular origin, 18.7 mm at the cheilion, 23.5 mm at the nasal ala). FA depth was varied between 5.98 mm and 6.62 mm at the mandibular origin, between 8.36 mm and 9.20 mm at the cheilion, between 9.52 mm and 10.51 mm at the nasal ala at a 95% confidence interval. CONCLUSIONS: This study suggests that there is no absolutely safe depth or region for nasolabial fold filler injections.

Amyloidosis Associated Kidney Failure with Gross Hypermetabolic Intra-abdominal Mass

A 23-year-old male patient who presented with impaired kidney function tests attended to hospital for hemodialysis and underwent 18F-FDG positron emission tomography/computed tomography (PET/CT) examination for the metabolic characterization of the intra-abdominal mass which was found in the ultrasonography. 18F-FDG PET/CT revealed a mass lesion adjacent to the liver which was hypermetabolic and the pathology of the lesion was determined as amyloidosis. To the best of our knowledge, the case with 18F-FDG PET/CT images of a huge amyloid mass is the first in the literature.

Temporal bone hemangioendothelioma as a rare vascular tumor in childhood: case report and review of the literature.

BACKGROUND: Hemangiondothelioma is a rare vascular tumor that can occur in the bone. Temporal bone involvement has been reported extremely rare in the literature. CASE: Radiological examination of a one-year-old girl who was admitted due to facial paralysis revealed vascular tumor of the temporal bone and Galen vein aneurysm. Pathological examination showed retiform hemangioendothelioma. She was treated with propranolol, prednisolone, vincristine, and endovascular embolization followed by oral sirolimus. With sirolimus treatment, a partial response was obtained first, then the tumor remained stable and sirolimus treatment was discontinued. No progression was observed in the disease after discontinuation of treatment. CONCLUSION: In this article, a case of hemangioendothelioma originating from the temporal bone is discussed in the light of other case reports in the literature.

Variations in the origins of the thyroid arteries on CT angiography.

OBJECTIVE: To investigate the anatomical variations in the origins of the thyroid arteries on CT angiography images. METHODS: The presence and the origins of the superior thyroid artery, the inferior thyroid artery, and the thyroidea ima artery were retrospectively evaluated based on carotid CT angiography examinations. The bifurcation level of the common carotid artery with respect to the cervical vertebrae and disc spaces was also determined. A total of 640 patients were included in the study. RESULTS: The right and left superior thyroid arteries arose from the external carotid artery in 413 (64.5%) and 254 (39.7%) patients, from the bifurcation of the common carotid artery in 131 (20.5%) and 148 (23.1%) patients, and from the common carotid artery in 90 (14.1%) and 226 (35.3%) patients, respectively. We could not observe the right and the left superior thyroid arteries in 6 (0.9%) and 12 (1.9%) of the patients, respectively. However, the right and left inferior thyroid arteries were not identified in 14 (2.2%) and 45 (7%) of the patients, respectively. The thyroidea ima artery was detected in 2.3% of the patients. CONCLUSION: The visualization of thyroid arteries on CT angiography images enables the anatomy of the arterial supply system of the thyroid gland to be explored in a noninvasive manner prior to surgery.

Clinical course of the untreated calcified big cerebellar liponeurocytoma.

Cerebellar liponeurocytoma (CLN) is a very rare tumor of central nervous system, classified as glioneuronal tumor by the latest classification of World Health Organization (WHO) in 2016. There are limited data in the literature about biologic behavior, growth pattern and radiological features of this tumor. In this case report, we operated a big calcified CLN patient who had denied any surgical procedures suggested by an another institute and had been followed for 4 years.

Hemolytic uremic syndrome and IgA nephropathy in a child: Coincidence or not?

Sürmeli-Döven S, Delibas A, Gürses I, Kayacan UR, Coskun-Yilmaz B, Esen K, Korkmaz E, Özaltin F. Hemolytic uremic syndrome and IgA nephropathy in a child: Coincidence or not? Turk J Pediatr 2018; 60: 81-85. A previously healthy 18-month old boy, presenting with diarrhea, anemia, thrombocytopenia and acute renal failure was admitted to our hospital. Hemolytic uremic syndrome (HUS) was diagnosed with his clinical and laboratory findings. His stool was negative for Shiga toxin producing E. coli (STEC). During follow-up he developed respiratory distress, hypertrophic cardiomyopathy and seizure. His genetic tests for atypical HUS (aHUS) were negative. His clinical and histological findings indicated hemolytic uremic syndrome and immunglobulin A nephropathy (IgAN). The patient responded to steroid treatment and plasma exchange therapy with peritoneal dialysis. We discuss the probable connection between HUS and IgAN.

Management of occipitocervical junction and upper cervical trauma.

OBJECTIVE: The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure. MATERIALS AND METHODS: Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18-87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner. RESULTS: Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1-C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion. CONCLUSIONS: Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.

Sonographic assessment of subacromial bursa distension during arm abduction: establishing a threshold value in the diagnosis of subacromial impingement syndrome.

PURPOSE: In this study, we aimed to establish a quantitative threshold value in the diagnosis of subacromial impingement syndrome by measuring the thickness of the subacromial bursa during abduction and adduction. MATERIALS AND METHODS: Forty-five patients with subacromial impingement syndrome and 54 healthy individuals underwent dynamic shoulder ultrasonography. The subacromial bursa, between the supraspinatus tendon margin and peribursal adipose tissue, was measured between the acromion and humeral head at its widest part. The subacromial impingement ratio was calculated by dividing the subacromial bursa thickness during abduction to the subacromial bursa thickness during adduction. Shapiro-Wilk test was used in the assessment of normal distribution of parameters. RESULTS: The mean subacromial bursa thickness in the abduction position was 1.8 ± 1.1 mm in the study group and 0.9 ± 0.3 mm in the control group. The mean subacromial bursa thickness in the adduction position was 0.9 ± 0.5 mm in the study group and 0.8 ± 0.3 mm in the control group. The subacromial impingement ratio showed a statistically significant difference between groups (p < 0.0001), and the ratio being 2.0 ± 0.5 in the study group and 1.2 ± 0.1 in the control group. For measurements performed in the abduction position, the best cut-off value was calculated as 1.3 mm, and sensitivity and specificity were 70.6 and 85.2%, respectively. The best cut-off value was 1.4 for the subacromial impingement ratio, and sensitivity and specificity were 88.2 and 96.3%, respectively. CONCLUSION: Subacromial impingement ratio is a very practical and reliable method in subacromial impingement syndrome diagnosis.