Median Nerve Axonotmesis Following Bleomycin Electrosclerotherapy: A Case Study of a Significant Complication After Treatment of a Lymphovascular Malformation

Bleomycin electrosclerotherapy (BEST) is a recently introduced treatment for lymphovascular malformations that combines intralesional bleomycin injection under image guidance with a precisely modulated electrical field to enhance cellular uptake. This technique is reported to have a favourable safety profile, with most adverse effects limited to transient pain and pigmentation. We report the case of a 20-year-old female patient who presented with severe, intractable pain in the left forearm and hand following BEST treatment for a forearm lymphangioma. Clinical examination demonstrated neuropathic pain with associated sensory deficit in the median nerve distribution. Due to concern for compartment syndrome, the surgical team performed urgent exploration of the forearm and a four-compartment fasciotomy. Postoperatively, the fasciotomy did not relieve symptoms, and subsequent clinical findings supported a diagnosis of direct, nonthermal electrical injury to the median nerve. Review of intraprocedural imaging revealed distortion of the electrode probe tip geometry. We hypothesize that this deformation resulted in an unintended increase in the focal electrical field, exceeding the threshold for irreversible electroporation, causing axonal injury, rather than the intended reversible electroporation required for drug delivery. To our knowledge, this report describes the first documented case of median nerve axonotmesis following BEST. Deformation of the electrode geometry may significantly increase focal electrical field strength and result in unintended nerve injury. Although BEST demonstrates efficacy and an overall favourable safety profile in the treatment of lymphovascular malformations, clinicians should remain aware of this potential complication to support informed consent and appropriate management of postoperative presentations that may mimic compartment syndrome.