In spite of recent advances in thoracic aortic surgery, postoperative neurological injury still remains the main cause of mortality and morbidity after aortic arch operation. The use of cardiopulmonary bypass (CPB) and hypothermic circulatory arrest, temporary interruption of brain circulation, transient cerebral hypoperfusion, and manipulations on the frequently atheromatic aorta all produce neurological damages. The basic established techniques and perfusion strategies during aortic arch replacement number three: hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP). During the past decade and after several experimental studies, RCP lost its previous place in the armamentarium of brain protection, giving it up to ACP as a major method of brain perfusion during HCA. HCA should be applied at a temperature of asymptotically equal to 20 degrees C with long-lasting cooling and rewarming and should not exceed by itself the time of 20-25 min. RCP does not seem to prolong safe brain-ischemia time beyond 30 min, but it appears to enhance cerebral hypothermia by its massive concentration inside the brain vein sinuses. HCA combined with ACP, however, could prolong safe brain-ischemia time up to 80 min. Cold ACP at 10 degrees -13 degrees C should be initially applied through the right subclavian or axillary artery and continued bihemispherically through the left common carotid artery at first and later the anastomosed graft, with a mean perfusion pressure of 40-70 mm Hg. The safety of temporary perfusion is being confirmed by the meticulous monitoring of brain perfusion through internal jugular bulb O2 saturation, electroencephalogram, and transcranial comparative Doppler velocity of the middle cerebral arteries.