Wrong-Way Eye Deviation During Eye Opening

In most cases, eye deviation caused by brain lesions points toward the side of the lesion in supratentorial strokes and away from the lesion in infratentorial strokes. However, in rare cases of supratentorial lesions, the eyes may deviate to the opposite side, a condition known as "wrong-way eye deviation." A woman in her 60s with a history of untreated hypertension and heavy smoking was found unconscious at home and brought to the emergency department. On arrival, she was comatose, with a Glasgow Coma Scale score of 4 (E1V1M2), complete right-sided paralysis, and rightward eye deviation. Notably, her eyes remained in the midline when closed but deviated abruptly to the right when forcibly opened. Imaging revealed a large infarction in the left cerebral hemisphere due to occlusion of the left internal carotid artery, though collateral circulation preserved flow to the left middle cerebral artery. Electroencephalography showed no epileptic discharges, and antiseizure medications had no effect. A diagnosis of atherothrombotic cerebral infarction was made, and medical treatment was initiated. The patient's level of consciousness gradually improved, but the unusual eye deviation persisted for nearly three weeks. This presentation is consistent with "wrong-way eye deviation," a rare finding where the eyes deviate away from the side of a supratentorial lesion. What made this case distinct was the appearance of this deviation only during eye opening. This suggests selective impairment of the anterior voluntary eye movement pathway with relative preservation of the posterior automatic pathway. Further case accumulation is essential to better understand this rare phenomenon.