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Aim: To present the 20-years experience of reconstruction surgery of brachiocephalic arteries at neurosurgical department in order to show possibilities of modern neurosurgical approach to this pathology. Methods: 2600 carotid reconstruction were performed in 2140 patients with different lesions of brachiocephalic arteries, aged from 5 to 89 years. Diagnostic algorithm included different methods of neurovisualization to reveal morphological changes of the brain, lesion severity , collateral flow and cerebral perfusion. During all carotid reconstructions we used multimodality neuromonitoring techniques(TCD, EEG and cerebral oximetry) and neurophysiologic testing. We used both general and loco-regional anesthesia types according to individual indications. Results: Surgery of carotid arteries was the most common type of reconstruction – performed in 1844 cases, among them carotid endarterectomies (1689 cases), surgery for carotid dysplasia (134) and extracranial aneurysms (21). STA-MCA bypasses were performed in 585 cases. Surgery of vertebral artery was performed in 117 cases and was presented with reconstructions of V1 segment of vertebral artery (81) and different types of extra-anatomic reconstructions (36). Rare neurosurgical pathology were neck tumors with carotid and neural sheath involvement – 54 cases. Loco-regional anesthesia was used in 27% of cases, mostly for geriatric patients or with severe somatic disease. Patients with multifocal stenotic lesions underwent staged surgical treatment in 418 cases (20%) –as well on extraxcranial as on intracranial vessels. During long-term follow-up in 97% cases we registered good patency of reconstructed arteries. The rate of specific complications was 4,4%, mortality – 0,4%. Conclusions: Brachiocephalic reconstructions must be performed not only by vascular surgeons, but also by neurosurgeons. Individual approach to each patient and different brain protection strategies during reconstructive surgery of brachiocephalic arteries help to avoid high rate of complications for patients with multiple steno-occlusive lesions. Level of surgical experience is the main factor for success of neurosurgery of brachiocephalic arteries.