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SummarySuccessful step-by-step treatment of a combined gunshot shrapnel injury of the brain, damaging the left middle cerebral artery (MCA) branches, and penetrating myocardium injury is discussed. Open brain and heart surgeries were performed. A left MCA pseudoaneurysm was formed postoperatively. Endovascular exclusion of the left MCA pseudoaneurysm was performed using detachable micro coils. Finally, plastic reconstruction of the posttraumatic cranial vault defect was performed using a dynamic titanium plate.Treatment of severe combined gunshot shrapnel brain injury with formation of MCA pseudoaneurysm and a penetrating myocardium injury requires a multimodal approach involving related specialists (neurosurgeon, cardiosurgeon and interventional radiologist).

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A case of treating of 59 years old patient with a multifocal occlusive and stenotic lesion of the main arteries of the head is described. Patients has occlusions of both internal carotid arteries, left external carotid artery, right vertebral artery, severe stenosis in the initial segment of the left subclavian artery and severe stenosis in the ostium of the left vertebral artery, with cognitive impairment and coordination disorders.A single-session stenting of the stenosis in the ostium of left vertebral artery with balloon-expan-dable elution-stent with usage of the modified Szabo anchor technique and stenting of the stenosis in the initial segment of the subclavian artery with a balloon-expandable peripheral stent was performed. Stenoses are eliminated, all cerebral arteries of the vertebrobasilar basin and both carotid basins are supplied by the left vertebral artery.After 50 days, the patient’s neurological status was assessed and a computed tomographic perfusiography of the brain was performed. The cognitive status improved significantly (initially – 23 points on the MoCA scale, after the operation – 27 points), coordination disorders regressed. According to computed tomographic brain perfusion, there are increase in CBF (cerebral blood flow) above normal in all areas except for the area of ​​stroke; an increase in CBV (cerebral blood volume) above normal, which is a reflection of arterioles vasodilation; increase in MTT (mean transit time) in all zones, which is a sign of collateral blood flow. Based on these data, it was concluded that further revascularization operations on the occluded cerebral arterial basins can lead to the hyperperfusion syndrome clinical manifestation. The performed endovascular stage of treatment was effective and sufficient to significantly improve the patient’s neurological and cognitive status and prevent the development of recurrent ischemic stroke.