Brain and spinal cord injuries are some of the most troublesome sequelae during perioperative periods of cardiovascular surgery, which decrease the patient quality of life in the long term and can subsequently lead to serious morbidity and mortality. In cardiac surgery, one cause of perioperative cerebral complications is cardiopulmonary bypass (CPB). Off-pump coronary artery bypass grafting, particularly with a non-touch aortic technique, has been developed for preventing cerebral deficits. Other crucial issues are intraoperative examination of the ascending aorta with epiaortic echo and appropriate selection of alternative CPB cannulation sites such as the axillary or femoral arteries. On the other hand, in a variety of recently advanced endovascular aortic repair techniques, protection of the central nervous system is of greater concern, because the perfusion vessels of the brain, spinal cord, or both are involved in the surgical repairs. Hypothermia is still the underlying principle for cerebrospinal protection methods, because of the increased safety margin for preventing ischemic injury. Based on mild to moderate hypothermia, several kinds of antegrade and retrograde perfusion modalities are used for more secure protection. However, since they do not always provide complete cerebrospinal protection, several technical or pharmacological adjuncts should be added. These include precise preoperative examination of aortic and arterial lesions including identification of the Adamkiewicz artery, perioperative neuromonitoring with regional cerebral oxygenation and motor-evoked potentials, and various pharmacological methods.