Reflection and Reaction 792 http://neurology.thelancet.com Vol 4 December 2005 group, but consistent with other studies. In 2004, Henkes and colleagues 12 published a large series of 1811 aneurysms treated by endovascular coil occlusion with nearly identical corresponding occlusion rates. In keeping with the angiography results, technical outcomes in ISAT clearly show that if endovascular coiling is attempted it is more likely to fail than an attempt at surgical treatment of ruptured aneurysms. This result is revealed by the 6·1% (66/1080) of patients in the endovascular group and 1·4% (14/1004) of patients in the surgery group in whom the first procedure attempted was not completed (p0·0001). Overall, rehaemorrhage rates were not significantly different between the endovascular and surgical groups. However, a larger proportion of patients randomised to surgery than to the endovascular intervention bled before the procedure. Because risk of rebleeding is greatest within the initial period after subarachnoid haemorrhage, this discrepancy could be accounted for by the significant difference in time between randomisation and the first procedure for the two treatment groups (1·1 days for endovascular and 1·7 days for surgery). 2 If patients who rebled before any intervention are then excluded, the resulting significant difference favours a reduced rate of rebleeding in surgically treated patients (p=0·004). Despite these cautions, ISAT is a well-executed and statistically powerful study. Its randomisation and large patient population give us confidence to use some of the information to make evidence-based treatment decisions for certain ruptured intracranial aneurysms. The ongoing collection of data from ISAT will continue to yield information about the durability and long-term efficacy of endovascular coiling compared with surgical clipping. As techniques continue to improve, however, more aneurysm locations and conformations will become accessible and amenable to endovascular interventions, which will continue to raise the question of whether surgery or coiling is the best treatment for our patients. Alim P Mitha, Christopher S Ogilvy Massachusettes General Hospital, Boston, USA cogilvy@partners.org We have no conflicts of interest. 1 Koivisto T, Vanninen R, Hurskainen H, Saari T, Hernesniemi J, Vapalahti M. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms: a prospective randomized study. Stroke 2000; 31: 2369–77. 2 Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360: 1267–74. 3 Molyneux AJ, Kerr RSC, Yu L-M, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366: 809–17. 4 Ogilvy CS. Neurosurgical clipping versus endovascular coiling of patients with ruptured intracranial aneurysms. Stroke 2003; 34: 2540–42. 5 Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The International cooperative study on the timing of aneurysm surgery, part 1: overall management results. J Neurosurg 1990; 73: 18–36. 6 Raymond J, Roy D. Safety and efficacy of endovascular treatment of acutely ruptured aneurysms. Neurosurgery 1997; 41: 1235–46. 7 Qureshi AI, Suri MF, Nasar A, et al. Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States. Neurosurgery 2005; 57: 1–8. 8 Byrne JV, Sohn MJ, Molyneux AJ. Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding. J Neurosurg 1999; 90: 656–63. 9 Hoh BL, Topcuoglu MA, Singhal AB, et al. Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 2004; 55: 779–89. 10 Harbaugh RE. ISAT study: is coiling better than clipping? Surg Neurol 2003; 59: 165–67. 11 Britz GW. ISAT trial: coiling or clipping for intracranial aneurysms? Lancet 2005; 366: 783–85. 12 Henkes H, Fischer S, Weber W, et al. Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results. Neurosurgery 2004; 54: 268–85. In Newsdesk (August, 2005), 1 new evidence for the neuroanatomy of remote memory was reported. On the basis of the findings of the US team lead by Larry Squire, 2 remote autobiographical memory was suggested to be independent of the medial temporal lobe but dependent on the neocortex. By contrast with previous hypotheses, this new proposal predicts that after damage to the medial temporal lobe only recent autobiographical memories should be impaired in neurological patients, whereas loss of both recent and old autobiographical memories implies additional damage in the neocortex. However, there is evidence not included in the Newsdesk article, that is problematic for this new prediction. Two patients, NT and VC, were previously reported to have lesions restricted to the medial temporal lobe and exhibited loss of remote memories extending for decades. Patient NT presented with extensive and The hippocampus and remote autobiographical memory