Can a stroke cause abductor drift of the eye?

Stroke and Eye Deviation: Understanding Conjugate Gaze Deviation

Yes, stroke can cause conjugate eye deviation (not "abductor drift"), where both eyes deviate together toward the side of the brain lesion, typically resolving within 48 hours in most cases. 1

What Actually Happens with Eye Position in Stroke

Conjugate eye deviation is the correct term for what occurs after hemispheric stroke, where both eyes deviate together as a unit, not "abductor drift" which is not a recognized clinical entity. 1, 2

Typical Pattern (Prévost's Sign)

• Both eyes deviate toward the side of the lesion (ipsilesional deviation) in acute hemispheric stroke 1, 2
• This occurs because the frontal eye field on the damaged side can no longer drive gaze to the opposite side 1
• The patient appears to be "looking at the lesion" or "looking away from the paralyzed limbs" 1

Time Course and Recovery

• 57% of patients recover within 48 hours 1
• 90% recover within 5 days 1
• Early disappearance of eye deviation is an isolated phenomenon that precedes improvement in other neurological deficits 1
• Recovery is mediated by the contralateral unaffected frontal eye field taking over control 1

When Eye Deviation Persists Longer

Prolonged conjugate eye deviation (13-43+ days) occurs specifically when there is pre-existing damage to the contralateral frontal lobe. 1 This prevents the unaffected hemisphere from compensating for the acute stroke.

Special Association with Spatial Neglect

In right hemisphere stroke with spatial neglect, eye and head deviation is particularly marked and consistent:

• Every single patient with right hemisphere stroke and spatial neglect shows marked rightward deviation 2
• Average spontaneous gaze position is 46 degrees to the right 2
• Patients without neglect have eye positions close to midline (0 degrees), regardless of stroke side 2
• The presence of marked horizontal eye and head deviation approximately 1.5 days post-stroke serves as a clinical marker for spatial neglect 2

Wrong-Way Deviation: The Exception

Contralateral eye deviation (away from the lesion) is rare (1.2% incidence) but carries grave prognostic significance: 3

• Occurs with huge intracranial hemorrhages or extensive hemispheric infarctions 3
• Left-sided lesions are most frequent (66.7%) 3
• Usually appears a few days after initial insult, not immediately 3
• Frequently accompanied by transient downward eye deviation (58.3%) 3
• Indicates secondary damage to the rostral brainstem where oculomotor pathways cross 3
• Immediate surgical decompression may be necessary as conservative management yields poor outcomes 3

Clinical Assessment

The National Institutes of Health Stroke Scale (NIHSS) includes assessment of gaze: 4

• 0 = Normal horizontal eye movements
• 1 = Partial gaze palsy
• 2 = Forced eye deviation or total paresis that cannot be overcome by Doll's eyes maneuver

Important Caveats

• Eye deviation is assessed through voluntary or reflexive movement (Doll's eyes maneuver, not calorics) 4
• The term "abductor drift" is not standard terminology; you are likely observing conjugate gaze deviation 1, 2
• Isolated eye movement disorders affect over 70% of stroke patients and can include various abnormalities beyond conjugate deviation 5, 6
• Retinal artery occlusions are stroke equivalents requiring emergency evaluation, but these cause visual loss rather than eye deviation 7