Background After cardioversion of atrial fibrillation the risk for cerebral embolism is increased. There is little knowledge about the incidence of cerebral embolism for patients with transesophageal echocardiography (TEE)-guided cardioversion under oral anticoagulation. Methods Consecutive patients with atrial fibrillation and TEE-guided cardioversion were included in the study. We performed serial TEE studies, Holter electrocardiography, cranial magnetic resonance imaging, and clinical examinations during a period of 4 weeks before and after cardioversion. Oral anticoagulation was continued or initiated in all patients. Results During the observation period 6 of 127 (4.7%) patients had new embolic lesions after cardioversion documented on cerebral magnetic resonance imaging. Patients with an event were significantly older ( P = .04) and had a larger left atrium ( P = .04) than patients without event. Conclusion Patients with atrial fibrillation and oral anticoagulation have a low rate of clinical apparent cerebral embolism after TEE and anticoagulation-guided cardioversion. The rate of silent cerebral embolism is almost 5%. Age and left atrial size are predictors for an event.