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Neurological injuries, stroke and paraplegia are the most devastating complications of aortic surgery. Historically, these two complications have been considered separately; investigation and discussion of arch surgery has concentrated on the risk of injury to the brain while discussion of descending and thoraco-abdominal aortic surgery has concentrated on the risks and avoidance of spinal cord injury (SCI). The report from Professor Griepp’s laboratory in this issue of the journal [1] clearly demonstrates that this convenient compartmentalisation of neurological injury by site of surgery is an oversimplification and that for aortic arch surgery, protection of the spinal cord as well as the brain is an important concern. The reason that this concern has manifested itself is the increasingly popular trend towards the performance of aortic arch surgery at warmer temperatures. Confidence in the ability of selective antegrade cerebral perfusion (SACP) to protect the brain, together with an effort to reduce some of the purported disadvantages of hypothermia and longer cardiopulmonary bypass (CPB) times has meant that arch surgery is now being performed at almost any temperature between 15 8C and 37 8C. This means that the period of corporeal (and thus spinal cord) ischaemia is endured by the patient at higher temperature. Consequently, there is a potential increased risk of SCI. Aortic arch surgery requires temporary interruption of the cerebral, spinal and corporeal circulation. To prevent brain injury, a number of neuroprotective measures have been studied. Profound cooling of the whole patient to temperatures of 15—20 8C reduces cerebral blood flow and oxygen consumption, thereby increasing the ischaemic tolerance of both the brain and every other tissue cooled, including the spinal cord. The extension that such cooling gives to the safe duration of brain circulatory arrest is however limited and human data suggest that the safe duration of hypothermic circulatory arrest (HCA) may be as low as 20 min at 20 8C and 30 min at 15 8C. Not surprisingly, clinical arrest times greater than 25 min at deep hypothermia carry an increased risk of transient neurological deficit and arrest times greater than 40 min are associated with an increased risk of stroke and mortality [2]. However, the spinal cord is less vulnerable to ischaemia than the brain [3] and, consequently, there are

european journal of cardio-thoracic surgery

The brain, the spinal cord, selective antegrade cerebral perfusion and corporeal arrest temperature — are we reducing the margin of patient safety in aortic arch surgery?