Learning points► It is essential to maintain strict vigil in tracheostomised patients about the care of the tracheostomy site with preemptive tube changes advocated in any risk of displacement. ► The imaging in management of tracheostomy tube dislodgement is of paramount importance, irrespective of the clinical status or relief of respiratory distress.

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Haemodynamic flow-related stress at the vessel curvatures is an important risk factor for intracranial aneurysmal growth and rupture. The rete middle cerebral artery (MCA) is a rare entity causing hyperdynamic blood flow into the ipsilateral anterior cerebral artery (ACA), especially when the contralateral A1-segment is non-dominant. Ruling out the clinicoradiological mimics like vasculitis, moyamoya and chronic occlusive disease with vessel wall imaging and detailed investigations helps manage the clinical entity effectively. We present a successfully managed case of ruptured ACA aneurysm at the acute curvature of the A1–A2 junction associated with ipsilateral rete MCA. Pre-emptive diagnosis of the rete MCA can aid preventive strategies to manage rupture and regrowth of the aneurysm at the points of flow-related stress.

The catheter movement and stability in coiling of very small aneurysms is challenging. We describe a technique for controlled catheter movement and successful coiling of a very small aneurysm.

No abstract