Background: Cerebral injury after total arch replacement remained one of devastating complications, which require strategies for its prevention and treatments. In the present study we retrospectively evaluated the factors related to symptomatic cerebral injury after total arch replacement. Methods: Twenty five patients who underwent total arch replacement under selective cerebral perfusion with hypothermia were included for analysis. The associations between the development of postoperative symptomatic cerebral injury and perioperative factors were analyzed. Results: Symptomatic cerebral injury developed in 6 patients (24%), of which 4 patients (16%) had transient symptoms. The patients with cerebral injury had higher incidence of preoperative ischemic heart disease compared with those without injury. In patients with injury, the lowest temperature during circulatory arrest was lower, and cardiopulmonary bypass time, aortic clamp time were longer than those without injury. Total doses of fentanyl were larger in patients with injury than those without injury. Conclusion: These results suggest that the incidence of cerebral injury after total arch replacement was high and the risk factors related to cerebral injury were preoperative ischemic heart disease, lowest tympanic temperature, cardiopulmonary bypass time, aortic clamp time, and fentanyl doses.