BackgroundTourniquet deflation following total knee arthroplasty (TKA) frequently results in release of emboli into the pulmonary circulation. Small emboli may gain access to the systemic circulationviaa transpulmonary route or through a patent foramen ovale. This study examined the incidence of cerebral microembolism after tourniquet release by transcranial Doppler (TCD) ultrasonography and its correlation with echogenic material detected in the left atrium.MethodsTwenty‐two adult patients (9 men, 13 women) undergoing TKA were studied with simultaneous TCD ultrasonography and transesophageal echocardiography. Data were recorded after anesthesia induction and tourniquet inflation and during tourniquet deflation. Emboli counts were performed manually off‐line. Echogenic material in the left atrium was qualitatively assessed and correlated with TCD data. Patients were examined postoperatively for focal neurologic deficits.ResultsFifteen patients had unilateral TKA (six left, nine right) and seven had bilateral TKA. Cerebral emboli were detected in 9 of 15 patients (60%) with unilateral TKA and in 4 of 7 patients (57%) with bilateral TKA. Echogenic material was identified in the left atrium in eight patients (two through a patent foramen ovale and six from the pulmonary veins). Emboli counts were significantly higher in patients with bilateral TKA compared with those with unilateral TKA (P< 0.05). Duration of tourniquet time in patients with emboli was longer only during bilateral TKA (P< 0.05). All patients with echogenic material in the left atrium detected by transesophageal echocardiography had emboli as assessed by TCD ultrasonography. No focal neurologic deficits were identified.ConclusionsCerebral microembolism occurs frequently during tourniquet release, even in the absence of a patient foramen ovale. This passage most likely occurs through the pulmonary capillaries or the opening of recruitable pulmonary vessels.