The findings support the start of a multicenter randomized trial to assess the clinical value of embolus detection in TIA and stroke care. During this study we observed that some patients learn more with

a low ABCD2 score may exhibit ongoing cerebral embolism and other patients with high score ABCD2 scores did not always show cerebral embolism and vice versa. It seems that both methods could in a way be complementary as the EDS results are more indicative for plaque stability while some of the ABCD2 score components are more indicative for plaque formation (such as age, blood pressure and diabetes). This study showed that EDS monitoring can be used for diagnosis and monitoring unstable carotid artery disease and gave insight in the epidemiology of cerebral embolism. MES were seen during the diastolic phase of the cardiac cycle and disappeared by anti-thrombotic drugs or plaques removal. The aforementioned aspects of the MES could best be explained by the

hypothesis that these MES were generated by small solid particles that were disloged into the circulation by unstable carotid artery stenosis [9]. In some patients we noted >12 MES in 30 min which means that hundreds of these small particles Erastin order must go to the brain within a 24 h timeframe. Only a minority of these micro emboli resulted in TIA’s or minor strokes. It seemed that the normal brain has the capacity to clear these of tiny micro-emboli. An important aspect is the duration of monitoring that is needed to detect emboli. Previous studies showed that embolism is from non-continuous phenomenon so it might be that very short observation times result in false negative monitoring results. The present study however shows that 30 min of monitoring gives relevant clinical information which, in combination with a zero-tolerance regime can, reduce the stroke recurrence rate. If the frequency of embolism is high the observation time might be limited less than 30 min. We feel that the time that is needed to document at least two MES is the minimum time for embolus detection. Future

studies with ambulatory TCD systems will focus on the value of extended embolus detection beyond the 30 min [10]. This study showed that therapeutical interventions could arrest ongoing cerebral embolism. This was observed after angioplasty, carotid stenting or after a drug switch to clopidogrel. The latter is in accordance with the CARESS trial [11] which showed that in patients with recently symptomatic carotid stenosis, combination therapy with clopidogrel and aspirin is more effective in reducing asymptomatic embolism. Although the number of observation are small in the present study Table 4 indicates a trend that patients who experienced cerebral embolism have a different vascular profile than those who do not exhibit cerebral embolism. Embolus positive patients showed in contrast to embolus negative patients more retinal and cortical TIA in combination with a symptomatic high-grade carotid artery stenosis.