Surgical reconstruction of the aortic arch is a complex procedure requiring careful preoperative analysis of the pathology and forethought toward surgical approach. Development of surgical techniques has brought dramatic improvement survival and reduction of neurological events associated with these procedures, yet significant morbidity is still encountered. New approaches to the patient with these pathologies include antegrade and retrograde perfusions to the brain. Continued research into physiology of hypothermic circulatory arrest offers the promise of pharmacological protection of the brain during aortic reconstruction and potentially development of therapeutic modalities to treat and limit ischemic brain damage.