Neuroanatomy SECOND EDITION Matthew H. Rouse, SLP.D. Associate Professor and Chair Communication Disorders Biola University, La Mirada, California World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2020 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. 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Parker Cover Printing: LSC Communications Library of Congress Cataloging-in-Publication Data Names: Rouse, Matthew H., author. Title: Neuroanatomy for speech-language pathology and audiology / Matthew H. Rouse. Description: Second edition. | Burlington, Massachusetts: Jones & Bartlett Learning, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2018052232 | ISBN 9781284151060 Subjects: | MESH: Communication Disorders | Neurologic Manifestations | Central Nervous System—anatomy & histology | Central Nervous System Diseases—pathology | Nervous System Physiological Phenomena Classification: LCC RC423 | NLM WL 340.2 | DDC 616.85/5—dc23 LC record available at https://lccn.loc.gov/2018052232 6048 Printed in the United States of America 23 22 21 20 19 10 9 8 7 6 5 4 3 2 1 This book is dedicated to three sets of people: To my wife, Chrissie, and my daughters, Torie and Lexie… thank you for your gracious gift of time to complete this work. To my parents… thank you for your years of love, commitment, and encouragement. To my neuroanatomy students… thank you for your feedback. You have all made this text better. © VeraPetruk/Getty Images Brief Contents Preface xiii About the Author xvii Reviewers xix PART I Introductory Issues 1 Chapter 1 Introduction to Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter 2 Navigation and Organization of the Nervous System . . . . . 27 Chapter 3 Development of the Nervous System . . . . . . . . . . . . . . . . . . 45 PART II General Neuroanatomy 59 Chapter 4 The Cells of the Nervous System . . . . . . . . . . . . . . . . . . . . . . 61 Chapter 5 The Spinal Cord, Brainstem, Cranial Nerves, and Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Chapter 6 Diencephalon, Basal Ganglia, and Brain Ventricles . . . . . . 131 Chapter 7 The Cerebrum: A Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Chapter 8 The Cerebrum: Cerebral Function . . . . . . . . . . . . . . . . . . . . . 175 PART III Neuroanatomy Applied to Communication and Communication Disorders 201 Chapter 9 Consciousness and Disorders of Consciousness . . . . . . . . . 203 Chapter 10 The Neurology of Hearing and Balance . . . . . . . . . . . . . . . . 223 v vi Brief Contents Chapter 11 The Neurology of Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Chapter 12 The Neurology of Language . . . . . . . . . . . . . . . . . . . . . . . . . 263 Chapter 13 The Neurology of Swallowing . . . . . . . . . . . . . . . . . . . . . . . 289 Chapter 14 The Neurology of Cognition . . . . . . . . . . . . . . . . . . . . . . . . . 305 Chapter 15 The Neurology of Emotion . . . . . . . . . . . . . . . . . . . . . . . . . . 323 PART IV Practicing Neuroanatomy 337 Chapter 16 The Neurological Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Glossary 355 Index 371 © VeraPetruk/Getty Images Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii Chapter 2 Navigation and Organization About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii of the Nervous System . . . . . . . . . . 27 Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Navigation of the Nervous System . . . . . . . . . . . . . . . . .28 PART I Introductory Issues 1 Anatomical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 The Anatomical Position . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Anatomical Versus Clinical Orientation . . . . . . . . . . . . .31 Chapter 1 Introduction to Neurology . . . . . . . 3 Body Planes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Directional Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Introduction: Defining Neurology . . . . . . . . . . . . . . . . . . .4 Muscle Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 The Need for Neurological Training . . . . . . . . . . . . . . . . .5 Organizational Approaches A Broad Overview of the Nervous System . . . . . . . . . . .5 to the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . .36 The Nervous System Is a Precious Resource . . . . . . . . . . 5 An Anatomical Approach . . . . . . . . . . . . . . . . . . . . . . . . . .36 What Does Neurology Mean to Me? . . . . . . . . . . . . . . . . . 6 A Functional Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Famous People With Neurological A Developmental Approach . . . . . . . . . . . . . . . . . . . . . . . .42 Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The Approach of This Text . . . . . . . . . . . . . . . . . . . . . . . . . .42 Prevalence, Incidence, and Cost of Neurological Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Summary of Learning Objectives . . . . . . . . . . . . . . . . . .43 Classification of Neurological Disorders . . . . . . . . . . . . . . 9 Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 A Brief History of Neuroscience . . . . . . . . . . . . . . . . . . . .11 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Prehistory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Early History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . . .44 Later History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Modern History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Neuroscience Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Structural Imaging Techniques . . . . . . . . . . . . . . . . . . . . .18 Functional Imaging Techniques . . . . . . . . . . . . . . . . . . . .20 Chapter 3 Development of the Combined Structural and Functional Nervous System . . . . . . . . . . . . . . . 45 Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Which Test When? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 A Caution Regarding Imaging Techniques . . . . . . . . . .22 Genes, Chromosomes, and Cells . . . . . . . . . . . . . . . . . . .46 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Fertilization and the First Weeks of Life . . . . . . . . . . . . .48 Summary of Learning Objectives . . . . . . . . . . . . . . . . . .24 Structural Development of the Infant Brain . . . . . . . .49 Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Dorsal Induction (GA: 3–7 Weeks) . . . . . . . . . . . . . . . . . .49 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Ventral Induction (GA: 2–3 Months) . . . . . . . . . . . . . . . .51 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . . .25 Neural Proliferation (GA: 3–4 Months) . . . . . . . . . . . . . .53 Neuronal Migration (GA: 3–5 Months) . . . . . . . . . . . . . .53 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Cortical Organization and Synapse Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Formation (GA: 5 Months to Years Postnatal) . . . . .54 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Myelination (GA: Birth to Years Postnatal) . . . . . . . . . . .55 vii viii Contents Functional Development of the Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Infant Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 The Development of the Adolescent Brain . . . . . . . . .55 The Brain in Normal Aging . . . . . . . . . . . . . . . . . . . . . . . .56 Chapter 5 The Spinal Cord, Brainstem, Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Cranial Nerves, and Cerebellum . . . .93 Summary of Learning Objectives . . . . . . . . . . . . . . . . . .56 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 The Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Spinal Cord Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . . .57 Spinal Cord Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Select Disorders of the Spinal Cord . . . . . . . . . . . . . . . .103 Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 External Organization of the Brainstem . . . . . . . . . . . .107 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Internal Organization of the Brainstem . . . . . . . . . . . .110 Select Disorders of the Brainstem . . . . . . . . . . . . . . . . . .111 The Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 PART II General Neuroanatomy 59 Cranial Nerve I: The Olfactory Nerve . . . . . . . . . . . . . . .112 Cranial Nerve II: The Optic Nerve . . . . . . . . . . . . . . . . . .112 Chapter 4 The Cells of the Cranial Nerve III: The Oculomotor Nerve . . . . . . . . . . .117 Nervous System . . . . . . . . . . . . . . . 61 Cranial Nerve IV: The Trochlear Nerve . . . . . . . . . . . . . .118 Cranial Nerve V: The Trigeminal Nerve . . . . . . . . . . . . .118 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Cranial Nerve VI: The Abducens Nerve . . . . . . . . . . . . .118 Historical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . .62 Cranial Nerve VII: The Facial Nerve . . . . . . . . . . . . . . . . .119 Cell Structure and Function . . . . . . . . . . . . . . . . . . . . . . .63 Cranial Nerve VIII: The Vestibulocochlear (or Auditory) Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Molecules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 Cranial Nerve IX: The Glossopharyngeal Nerve . . . . .121 The Cell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 Cranial Nerve X: The Vagus Nerve . . . . . . . . . . . . . . . . . .121 Cells, Tissues, and Systems . . . . . . . . . . . . . . . . . . . . . . . . . .64 Cranial Nerve XI: The Spinal An Overview of Nervous System Cells . . . . . . . . . . . . .64 Accessory Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122 Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Cranial Nerve XII: The Hypoglossal Nerve . . . . . . . . . .122 Glial Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 The Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Neuron Form and Function . . . . . . . . . . . . . . . . . . . . . . . .67 Anatomy of the Cerebellum . . . . . . . . . . . . . . . . . . . . . . .123 Neuron Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Cerebellar Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 Important Aspects of Neuron Function . . . . . . . . . . . . .74 Select Disorders of the Cerebellum . . . . . . . . . . . . . . . .125 The Firing Neuron: The Analogy of a Gun . . . . . . . . . . .76 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 The All- or-None Principle . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Summary of Learning Objectives . . . . . . . . . . . . . . . . 126 Select Disorders of Nervous System Cells . . . . . . . . . .82 Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Intellectual Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Amyotrophic Lateral Sclerosis . . . . . . . . . . . . . . . . . . . . . .85 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . 128 Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Guillain–Barré Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . .87 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 Summary of Learning Objectives . . . . . . . . . . . . . . . . . .88 Chapter 6 Diencephalon, Basal Ganglia, Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 and Brain Ventricles . . . . . . . . . . . 131 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . . .89 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 The Diencephalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Contents ix Thalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 Age Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Subthalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Transference Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Hypothalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Interference Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Epithalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 The Basal Ganglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Summary of Learning Objectives . . . . . . . . . . . . . . . . 171 Structure and Function of the Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Basal Ganglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Internal Capsule and Corona Radiata . . . . . . . . . . . . . .140 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . 172 Basal Ganglia Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .140 The Brain Ventricles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Disorders of the Ventricles . . . . . . . . . . . . . . . . . . . . . . . . .146 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Summary of Learning Objectives . . . . . . . . . . . . . . . . 147 Chapter 8 The Cerebrum: Cerebral Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Function . . . . . . . . . . . . . . . . . . . . . 175 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . 148 The Cerebral Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Frontal Lobe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Parietal Lobe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Occipital Lobe: The Visual Cortex . . . . . . . . . . . . . . . . . .188 Temporal Lobe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Chapter 7 The Cerebrum: A Survey . . . . . . . . 151 Insular Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 The Protection and Nourishment Summary of Learning Objectives . . . . . . . . . . . . . . . . 196 of the Cerebrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Protection: The Meninges . . . . . . . . . . . . . . . . . . . . . . . . .152 Draw It to Know It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Protection: The Blood–Brain Barrier . . . . . . . . . . . . . . . .153 Questions for Deeper Reflection . . . . . . . . . . . . . . . . . 197 Nourishment: The Cerebral Arteries . . . . . . . . . . . . . . .156 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Waste Removal: The Venous System . . . . . . . . . . . . . . .158 Suggested Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 The Cerebrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Important Cerebral Landmarks . . . . . . . . . . . . . . . . . . . .158 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Layers of the Cerebral Cortex . . . . . . . . . . . . . . . . . . . . . .160 The Lobes of the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . .160 Hemispheric Specialization and Connections . . . . 161 PART III Neuroanatomy Applied Hemispheric Specialization . . . . . . . . . . . . . . . . . . . . . . . .161 to Communication and Inter- and Intrahemispheric Connections . . . . . . . . . .162 Communication Disorders 201 Cerebral Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Cerebral Vascular Accident . . . . . . . . . . . . . . . . . . . . . . . .163 Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 Chapter 9 Consciousness and Disorders Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167 of Consciousness . . . . . . . . . . . . . . 203 Stuttering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Brain Plasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 What Is Consciousness? . . . . . . . . . . . . . . . . . . . . . . . . . 204 Use It or Lose It and Use It and Improve It . . . . . . . . .169 Specificity Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 The Neurology of Consciousness . . . . . . . . . . . . . . . . 204 Repetition and Intensity Matter . . . . . . . . . . . . . . . . . . .170 Neural Mechanisms of Wakefulness . . . . . . . . . . . . . . .204 Time Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Neural Mechanisms of Core Consciousness Salience Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 and Extended Consciousness . . . . . . . . . . . . . . . . . .205