**6. Summary and recommendations**

The predominant cause for cerebral atheroma embolism in cardiac surgery using cardiopulmonary bypass relates to dislodgement of aortic atheroma with embolism caused by manipulation of the aorta. Transoesophageal echocardiography is not able to visualise the distal ascending aorta and proximal aortic arch due to the presence of air in the bronchi crossing between aorta and oesophagus. Epiaortic ultrasound is able to assess this portion of the aorta; and in addition is far more accurate than manual assessment by the surgeon's finger. Avoiding the atheroma however, requires a change to the surgical strategy.

A standardised comprehensive echocardiography protocol is proposed. The performance of this ultrasound examination is relatively straightforward and is fairly easily taught. It is recommended that it be before routinely.
