Coexisting secondary intraneural and vascular adventitial ganglion cysts of joint origin: A causal rather than a coincidental relationship supporting an articular theory

Objective: To introduce the clinical entity of an intraneural ganglion cyst coexisting with a vascular adventitial cyst arising from the same joint. Design: Retrospective review. Patients: Two patients presented with pre dominantly deep peroneal neuropathy due to complex superior tibiofibular joint-related cysts. In addition to having peroneal intraneural ganglion cysts, these patients had vascular adventitial cysts: One involving a capsular arterial branch, the other a capsular vein [as well as a large, recurrent, intramuscular (extraneural) ganglion]. We then reviewed MRIs of 12 other consecutive cases of intraneural ganglia (10 peroneal and 2 tibial) arising from the superior tibiofibular joint that we treated, as well as other reported cases in the literature to determine if there were other (unrecognized) examples supporting the combination of clinical findings and radiographic patterns. Results: Retrospective analysis of MRIs in the two surgically proven cases of peroneal intraneural ganglia with vascular adventitial cyst extension showed a common imaging pattern that we have termed "the wishbone sign," consisting of the connection of the ascending limb of the peroneal intraneural ganglion and the longitudinal limb of the vascular adventitial cyst in the axial plane. Our review suggests that vascular adventitial cyst extension occurs in a large proportion of cases of peroneal intraneural ganglia. A similar growth pattern was noted in a case of a tibial intraneural ganglion. Conclusions: The combination of intraneural and vascular adventitial cysts is understandable given our knowledge of normal and pathologic anatomy of para-articular cysts. The combination of intraneural ganglia and vascular adventitial cysts broadens the spectrum of clinical presentations of these cysts and suggests that cysts and their content can dissect from a joint along neurovascular bundles. These cases provide important evidence to support the articular theory for the pathogenesis of not only neural but vascular adventitial cysts as well.