Many patients who have cardiac surgery experience cerebral complications. Recently, the focus of interest has shifted from gross sequelae, such as stroke, to less conspicuous, but more frequent, neurologic and cognitive deficits. Although subtle, these deficits result in significant morbidity and resource use. Biochemical markers of cerebral injury have been used to identify these deficits. A multifactorial etiology, including emboli and cerebral hypoperfusion as well as genetic predisposition, has recently been proposed; there are distinct groups of patients who may be at very high risk. Intervention and prevention remain controversial, but there may be the possibility of pharmacologic protection. Although propofol has been found to be ineffective, lidocaine and remacemide may have some small benefit. Much interesting research has been published in the last year, but it may have raised more questions about the cerebral sequelae of cardiac surgery than it has answered.