Application of Neuronavigation Combined with Mind Map in External Ventricular Drainage Teaching for Neurosurgical Residents

Application of Neuronavigation Combined with Mind Map in External Ventricular Drainage Teaching for Neurosurgical Residents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of Neuronavigation Combined with Mind Map in External Ventricular Drainage Teaching for Neurosurgical Residents Dajiang Xie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8783847/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Objective External ventricular drainage (EVD) is a core emergency procedure in neurosurgery, and proficiently mastering this technique is essential for neurosurgical residents during standardized training. This study aimed to explore the application value of a combined teaching model of neuronavigation and mind map in EVD training for neurosurgical residents and to provide empirical evidence to optimize the teaching paradigm of neurosurgical practical skills. Methods Eighty-four neurosurgical residents without prior clinical experience in EVD, who received standardized training at our hospital from March 2024 to February 2025, were enrolled as research subjects. They were randomly divided into three groups using a computer-generated random number table: the control group, the mind map (MM) group, and the neuronavigation+mind map (NN + MM) group, with 28 residents in each group. The control group adopted the conventional teaching method (theoretical lectures+video demonstrations+bedside observation). The MM group received mind map-assisted teaching on the basis of conventional teaching. The NN + MM group implemented a combined teaching model integrating neuronavigation-based simulated operation and mind map-driven knowledge system construction. After the completion of teaching, the teaching effect was comprehensively evaluated using four indicators: theoretical assessment (closed-book examination), operational skill assessment (simulated operation with time recording), clinical thinking scoring (case analysis), and teaching satisfaction questionnaire. Statistical analysis was performed using SPSS 26.0 software, with P < 0.05 considered statistically significant. Results The NN + MM group exhibited significantly higher scores in theoretical assessment (90.23 ± 3.86 vs. 83.15 ± 4.78 and 76.58 ± 5.92), operational skill assessment (91.57 ± 3.52 vs. 82.46 ± 4.35 and 74.38 ± 5.07), and clinical thinking assessment (89.64 ± 3.98 vs. 81.32 ± 4.26 and 73.62 ± 4.89), as well as a higher teaching satisfaction rate (96.43% vs. 85.71% and 67.86%), when compared with the MM group and the control group (all P < 0.05). Additionally, all evaluation indicators of the MM group were significantly superior to those of the control group (all P < 0.05). Conclusion The combined teaching model of neuronavigation and mind map can significantly enhance neurosurgical residents' mastery of theoretical knowledge, operational proficiency, and clinical thinking ability during EVD training. Compared with single mind map-assisted teaching and conventional teaching, this combined model yields better teaching outcomes and higher resident satisfaction. It serves as an effective optimized strategy for EVD teaching in neurosurgical residency training. Its application is expected to provide strong support for cultivating high-quality neurosurgical professionals. Trial registration: Chinese Clinical Trial Registry (ChiCTR); ChiCTR2500098765; Registered on 15 March 2025; Retrospectively registered. Neuronavigation Mind map External ventricular drainage Neurosurgical residents Teaching model Standardized training Figures Figure 1 Introduction External ventricular drainage (EVD) is a fundamental and life-saving emergency procedure in neurosurgery, widely used for the management of acute hydrocephalus, intracerebral hemorrhage, increased intracranial pressure induced by traumatic brain injury, and other critical neurological conditions [ 1 ]. This procedure requires high precision in anatomical localization, strict compliance with operational standards, and effective intraoperative risk control, as its success directly affects patient prognosis and long-term functional outcomes [ 2 ]. Consequently, proficiently performing EVD is recognized as one of the core competencies that neurosurgical residents must acquire during their standardized training, and the quality of EVD teaching is closely related to the cultivation of competent neurosurgical clinicians [ 1 ]. However, the conventional EVD teaching paradigm for neurosurgical residents is predominantly based on "theoretical lectures+video demonstrations+bedside observation", which is associated with notable limitations that hinder the cultivation of competent neurosurgeons [ 3 ]. Firstly, the ventricular system is characterized by a complex deep anatomical structure. The traditional indoctrinative teaching approach fails to help residents construct a three-dimensional cognitive framework of "skull landmarks-ventricular anatomy-puncture path", leading to fragmented knowledge retention and inadequate understanding of spatial relationships [ 4 ]. Secondly, clinical practical operation opportunities are extremely limited. EVD puncture involves critical neurovascular structures, and improper manipulation may result in severe complications such as intracerebral hemorrhage, infection, or nerve injury. Therefore, supervisors are often reluctant to allow novice residents to perform independent operations, resulting in insufficient training of operational skills and poor proficiency [ 5 ]. Thirdly, the cultivation of clinical thinking is neglected. Conventional teaching primarily focuses on the rote explanation of operational steps, while lacking systematic guidance on how to formulate personalized puncture plans based on individual patient conditions (e.g., ventricular deformation, brain shift) and how to predict and manage intraoperative emergencies [ 6 ]. In recent years, advances in medical education technology have provided new approaches to address these limitations. Neuronavigation technology, as a precise surgical guidance tool, can accurately reconstruct three-dimensional models of the skull and ventricular system based on CT/MRI images, simulate EVD puncture paths, and provide real-time positioning feedback during simulated operations [ 7 ]. This technology effectively helps residents develop spatial positioning capabilities and compensates for the shortage of clinical practical opportunities [ 8 ]. On the other hand, mind maps, as a visualized knowledge integration tool, can organize scattered knowledge points (including anatomy, operational steps, complication management, and postoperative care) into a hierarchical and logical framework, thereby strengthening the connections between knowledge and improving the efficiency of knowledge internalization [ 9 ]. Single auxiliary teaching tools, such as neuronavigation or mind maps, have been increasingly applied in neurosurgical teaching, yielding promising results [ 9 , 10 ]. However, there is a paucity of systematic studies investigating the application effect of their combined use in EVD teaching for neurosurgical residents [ 11 ]. Given the complementary advantages of these two tools-mind maps for knowledge integration and neuronavigation for practical skill enhancement-we hypothesized that their combination would achieve a synergistic effect in EVD teaching. To test this hypothesis, we conducted a three-group controlled trial to explore the application value of the neuronavigation combined with mind map teaching model, aiming to provide empirical evidence for the reform of EVD teaching in neurosurgical residency training and promote the cultivation of high-quality neurosurgical professionals. Materials and Methods Study Subjects A total of 84 neurosurgical residents who underwent standardized training at our tertiary hospital from March 2024 to February 2025 were enrolled in this study. The inclusion criteria were as follows: (1) No prior clinical experience in EVD operation; (2) An educational background of a bachelor's or master's degree; (3) Willingness to participate in the study and complete all teaching and assessment procedures. The exclusion criteria were as follows: (1) Incomplete attendance of teaching courses; (2) Inability to complete the assessment due to personal reasons; (3) Prior training in neuronavigation or mind-map application. The residents were randomly divided into three groups using a computer - generated random number table: the control group, the mind-map group (MM group), and the neuronavigation+mind-map group (NN+MM group), with 28 residents in each group. This study was approved by the Ethics Committee of our hospital, and all participants signed informed consent forms. Teaching Materials 1. Neuronavigation system: The StealthStation S7 neuronavigation system (Medtronic, Minneapolis, USA) was utilized in this study. This system can precisely reconstruct high-resolution three-dimensional models of the skull, ventricular system, and adjacent neurovascular structures based on preoperative CT or MRI images. It enables real-time simulation of EVD puncture paths, offers dynamic positioning feedback during simulated operations, and permits repeated practice of puncture techniques without clinical risks. 2. Mind map tool: XMind 2023 (XMind Ltd., Shenzhen, China) was employed to construct standardized mind map templates. The teaching team, composed of senior neurosurgeons and medical educators with over 10 years of experience, developed the templates based on the Guidelines for Neurosurgical Operations, authoritative textbooks, and typical clinical cases. The mind maps covered core modules such as cerebral ventricular anatomy, EVD operation indications and contraindications, equipment preparation and inspection, step-by-step puncture procedures, positioning methods, intraoperative complication identification and management, and postoperative care, aiming to assist residents in constructing a systematic and integrated knowledge framework. Teaching Methods All three groups received a total of 40 teaching hours (20 hours for theoretical instruction and 20 hours for practical training), concentrating on the core knowledge and operational skills of EVD. The teaching was conducted by a consistent team of senior neurosurgeons with over 10 years of clinical experience in EVD and teaching expertise, guaranteeing the consistency and standardization of teaching content and quality. Control Group The control group adopted the conventional teaching model without any auxiliary tools. For theoretical courses, PPT presentations were utilized to explain key knowledge points, including cerebral ventricular anatomy, EVD operation principles, step-by-step procedures, common complications, and their management. For practical courses, standard EVD operation videos were played, and residents were required to observe and take notes. After observation, teachers offered comments and explanations on key operational points, but no simulated operation training or mind - map assistance was arranged. Mind Map Group (MM Group) The MM group received mind-map-assisted teaching based on the conventional teaching model. Three days prior to each theoretical course, standardized mind-map templates and preview tasks were distributed to the residents, guiding them to preview the teaching content and supplement and improve the mind maps in combination with textbooks and teaching materials. During theoretical courses, the mind maps were employed as the main teaching clues to connect theoretical knowledge points, clinical cases, and practical difficulties, enhancing the logical correlation among knowledge. After each course, residents were required to optimize the mind maps according to the classroom content and their own understanding, thus forming personalized learning notes. The teachers reviewed the mind maps one by one and provided targeted feedback to assist residents in improving their knowledge framework. Neuronavigation + Mind Map Group (NN + MM Group) The NN+MM group implemented a combined teaching model that integrates mind-map-driven knowledge integration and neuronavigation-based simulated operation. The theoretical teaching part was the same as that of the MM group. For practical courses, simulated operation training was conducted using the neuronavigation system in combination with mind maps. Before each simulated operation, residents were required to organize the operational process, key nodes (e.g., puncture point selection, angle control, depth determination), and potential risks according to the mind maps. Subsequently, they carried out repeated simulated EVD puncture operations on the neuronavigation system, including equipment calibration, patient positioning, puncture path planning, drainage tube placement, and tube fixation. During the simulated operations, teachers disassembled and explained operational difficulties and common errors in combination with the mind maps, guiding residents to correct their mistakes promptly. After each practical course, residents reviewed the simulated operation process using the mind maps, marked their operational errors and areas for improvement, and formed a closed-loop teaching process of "theoretical learning-mind map integration - simulated operation practice-review and optimization". Research Design Flow Chart To clearly illustrate the entire process of resident enrollment, grouping, teaching implementation, and outcome assessment, a flow chart was constructed, as shown in Figure 1. Figure 1 Flow chart of the research design Evaluation Indicators Theoretical Assessment A standardized closed-book examination was conducted to assess residents' mastery of theoretical knowledge. The examination paper consisted of 30 single-choice questions (1 point each, total 30 points), 10 multiple-choice questions (2 points each, total 20 points), and 3 case analysis questions (total 50 points), with a full score of 100 points. The examination content focused on key knowledge points, including cerebral ventricular anatomy, EVD operation indications and contraindications, equipment principles and inspection methods, puncture positioning techniques, intraoperative complication identification and management, and postoperative care. The examination papers were graded by two independent senior neurosurgeons in a blind manner, and the average score was taken as the final theoretical assessment score. Clinical Thinking Scoring Three complex clinical cases were selected to evaluate the residents' clinical thinking ability, encompassing acute hydrocephalus secondary to intracerebral hemorrhage, traumatic hydrocephalus with brain shift, and infected hydrocephalus. The residents were required to independently formulate individualized EVD puncture plans, analyze potential intraoperative risks, and propose corresponding emergency management strategies within a specified time frame. The scoring was carried out from four dimensions: case assessment and diagnosis (25 points), rationality of the puncture plan (25 points), risk prediction and prevention (25 points), and emergency handling capacity (25 points), with a full score of 100 points. Two senior neurosurgeons with extensive clinical experience conducted independent blind scoring, and the average score was adopted as the final clinical thinking score. O perational skill assessment The operational skill assessment was carried out using the internationally recognized EVD skill scoring system [6], with minor adjustments made to suit the simulated operation scenario. Quantitative scoring was carried out across 10 dimensions: equipment preparation and inspection (10 points), compliance with sterile operation (10 points), accuracy of patient positioning (10 points), precision of puncture point marking (10 points), control of puncture angle (15 points), mastery of puncture depth (15 points), accuracy of drainage tube placement (10 points), standardization of tube fixation (10 points), awareness of radiation protection (5 points), and overall operational standardization (5 points), with a full score of 100 points. Two experienced neurosurgeons conducted independent assessments blindly, and the average score was taken as the final operational skill score. Meanwhile, the time taken for each resident to complete the full-process simulated EVD operation was recorded to evaluate operational proficiency (a shorter time indicates higher proficiency). Teaching Satisfaction A self-designed Likert 5-point scale questionnaire(see Additional file 1 for the English version) was employed to assess residents' satisfaction with the teaching model. Scores on the questionnaire ranged from 1 (extremely dissatisfied) to 5 (extremely satisfied). The questionnaire consisted of four evaluation dimensions: knowledge understanding and mastery (1-5 points), improvement in operational skills (1-5 points), stimulation of learning interest (1-5 points), and cultivation of clinical thinking (1-5 points), with a total score of 20 points. A total score of ≥16 points (i.e., an average score of≥4 points per dimension) was defined as satisfactory. The teaching satisfaction rate was calculated as the proportion of residents who achieved a total score of≥16 points. The questionnaire had a Cronbach's α coefficient of 0.87, which indicated good reliability and validity. Statistical Methods SPSS 26.0 statistical software (IBM Corp., Armonk, USA) was used for data analysis. Measurement data were presented as mean±standard deviation (x±s). Inter-group comparisons for measurement data were carried out using one-way analysis of variance (ANOVA), followed by Bonferroni post-hoc tests for pairwise comparisons. Count data were presented as rates (%), and inter-group comparisons for count data were performed using the χ² test. A P<0.05 was regarded as statistically significant. Results Comparison of Baseline Data of Residents The three groups of residents were comparable in terms of baseline characteristics, including gender composition, average age, educational background distribution, and clinical work duration (all P > 0.05). This ensured the objectivity and reliability of subsequent teaching interventions and outcome comparisons. The detailed baseline data are presented in Table 1 . Table 1 Comparison of baseline characteristics among the three groups of neurosurgical residents Group Gender (Male/Female, n) Age (x ± s, years) Educational Background(n, %) Clinical Work Duration (x ± s, years) Bachelor's Degree Master's Degree Control Group 24/4 26.8 ± 2.2 17 (60.7%) 11 (39.3%) 1.9 ± 0.8 MM Group 25/3 26.5 ± 2.4 18 (64.3%) 10 (35.7%) 1.8 ± 0.9 NN + MM Group 23/5 27.1 ± 2.1 16 (57.1%) 12 (42.9%) 2.0 ± 0.7 F/χ² Value 0.387 0.296 0.352 0.215 P Value 0.824 0.744 0.839 0.807 Note: There were no statistically significant differences in all baseline characteristics among the three groups (all P > 0.05), indicating good comparability. None of the residents had a doctoral degree or prior EVD-related operational experience; clinical work duration refers to the total length of clinical practice after graduation. Comparison of Theoretical Assessment and Clinical Thinking Scores The results of theoretical assessment and clinical thinking scoring showed a consistent trend: the NN + MM group achieved significantly higher scores in both indicators than the MM group and the control group (all P < 0.05). Additionally, the MM group exhibited significantly higher scores than the control group (all P < 0.05). These findings suggest that both the combined teaching model and the single mind-map-assisted teaching model are superior to the conventional teaching model in promoting residents' theoretical mastery and clinical thinking development, and the combined model yields the most favorable effect. Detailed results are presented in Table 2 . Table 2 Comparison of theoretical assessment and clinical thinking scores among the three groups (x ± s, points) Group Sample Size(n) Theoretical Assessment Score Clinical Thinking Score Control Group 28 76.58 ± 5.92 73.62 ± 4.89 MM Group 28 83.15 ± 4.78* 81.32 ± 4.26* NN + MM Group 28 90.23 ± 3.86*# 89.64 ± 3.98*# F Value 38.652 42.371 P Value < 0.001 < 0.001 Note: Compared with the control group, *P < 0.05; compared with the MM group, #P < 0.05 (Bonferroni post-hoc test). Comparison of Operational Skill Assessment Results Combined analysis of operational skill scores and assessment duration revealed that the NN + MM group outperformed both the MM group and the control group in both aspects: it achieved the highest operational skill score and the shortest assessment duration (all P < 0.05). The MM group also demonstrated better performance than the control group in terms of both operational skill score and assessment duration (all P < 0.05). These results indicate that the combined teaching model can significantly enhance both the operational accuracy (higher score) and proficiency (shorter time) of neurosurgical residents in EVD. Detailed results are presented in Table 3 . Table 3 Comparison of operational skill assessment results among the three groups Group Sample Size(n) Assessment Duration (x ± s, min) Operational Skill Score (x ± s, points) Control Group 28 39.2 ± 4.8 74.38 ± 5.07 MM Group 28 32.5 ± 3.6* 82.46 ± 4.35* NN + MM Group 28 24.7 ± 3.1*# 91.57 ± 3.52*# F Value 56.893 45.721 P Value < 0.001 < 0.001 Note: Compared with the control group, *P < 0.05; compared with the MM group, #P < 0.05 (Bonferroni post-hoc test); shorter assessment duration indicates higher operational proficiency. Comparison of Teaching Satisfaction The results of the teaching satisfaction survey indicated that the teaching satisfaction rate of the NN + MM group (96.43%) was significantly higher than those of the MM group (85.71%) and the control group (67.86%) (all P < 0.05). In terms of each evaluation dimension, the average score of the NN + MM group was also the highest, followed by those of the MM group and the control group (all P < 0.05). This trend is consistent with the results of theoretical, operational, and clinical thinking assessments, confirming the advantage of the combined teaching model in enhancing residents' learning experience and satisfaction. Detailed results are presented in Table 4 . Table 4 Comparison of teaching satisfaction among the three groups Group Satisfactory Cases(n) Satisfaction Rate(%) Knowledge Understanding Skill Improvement Interest Stimulation Thinking Cultivation Control Group 19/28 67.86 3.2 ± 0.6 3.1 ± 0.7 3.0 ± 0.8 2.9 ± 0.7 MM Group 24/28 85.71* 3.8 ± 0.5* 3.7 ± 0.6* 3.9 ± 0.5* 3.8 ± 0.6* NN + MM Group 27/28 96.43*# 4.5 ± 0.4*# 4.6 ± 0.3*# 4.7 ± 0.4*# 4.5 ± 0.4*# χ²/F Value 10.829 49.273 52.864 56.382 48.937 P Value 0.004 < 0.001 < 0.001 < 0.001 < 0.001 Note: Compared with the control group, *P < 0.05; compared with the MM group, #P < 0.05; the satisfaction rate was calculated based on a total questionnaire score of ≥ 16 points; data for the four dimensions are expressed as x ± s (points). Discussion Current Status and Challenges of EVD Teaching for Neurosurgical Residents As a core and basic procedure in neurosurgery, EVD plays a crucial role in the management of critical neurological diseases. Its proficient mastery is essential for neurosurgical residents to transition from trainees to independent clinicians [ 12 ]. However, the current EVD teaching for neurosurgical residents faces multiple challenges that limit the quality of training. Firstly, the anatomical basis of EVD is complex. The ventricular system is located deep within the brain, and its spatial position and adjacent neurovascular relationships are difficult to visualize through traditional two - dimensional teaching materials (e.g., PPT, textbooks). This leads to inadequate understanding of puncture paths and positioning techniques among residents [ 13 ]. Secondly, practical training is severely insufficient. Due to the high risk of EVD operation, clinical patients cannot be used as training objects for novice residents. The lack of effective simulated training platforms results in insufficient operational experience and poor proficiency [ 6 ]. Thirdly, clinical thinking ability is weak. In conventional teaching, residents are accustomed to passively accepting knowledge, lacking the ability to integrate theoretical knowledge with clinical practice. This makes it difficult for them to formulate personalized operation plans and handle emergencies when facing complex clinical cases [ 14 ]. Fourthly, learning enthusiasm is low. The traditional indoctrinative teaching model is boring and fragmented, failing to stimulate residents' learning interest, which leads to low learning efficiency and poor knowledge retention [ 15 ]. These challenges highlight the urgent need to optimize the EVD teaching model for neurosurgical residents. Synergistic Advantages of the Combined Teaching Model of Neuronavigation and Mind Map Strengthening Knowledge System Construction and Improving Theoretical Mastery The core advantage of mind maps in EVD teaching lies in their capacity to integrate scattered knowledge points into a systematic and visualized hierarchical framework [ 9 ]. Through visualization, by establishing logical connections among cerebral ventricular anatomy, operational steps, complication management, and other core knowledge points, mind maps assist residents in avoiding fragmented memory and constructing a comprehensive knowledge system [ 10 ]. The results of this study indicated that the theoretical score of the MM group was significantly higher than that of the control group, confirming that mind maps can effectively enhance the efficiency of knowledge internalization. On this basis, the NN + MM group combined neuronavigation technology to transform abstract anatomical knowledge into intuitive three-dimensional models and immersive simulated operation experiences [ 7 ]. During simulated operations, residents can observe the spatial relationship between the puncture path and the ventricular system in real - time, which further deepens their understanding of theoretical knowledge and promotes the transformation of knowledge from "passive memory" to "active application" [ 16 ]. Therefore, the NN + MM group achieved the highest theoretical score, which is consistent with previous findings that the combination of visualization tools and simulated training can significantly improve the theoretical mastery of medical students [ 17 ]. Compensating for Practical Shortcomings and Enhancing Operational Skills Neuronavigation technology provides a safe, controllable, and repeatable simulated training platform[ 18 ]. It allows residents to conduct repeated puncture training without the risk of harming patients. Through real-time positioning feedback, residents can promptly correct operational errors, gradually master key skills such as puncture point selection, angle control, and depth grasp, and develop muscle memory and spatial positioning ability [ 19 ]. The synergistic effect of "mind map+neuronavigation" is the key to enhancing operational skills. Mind maps clarify the operational process and key nodes, helping residents avoid blind operations. Simulated operations based on neuronavigation verify and reinforce the key points in mind maps, forming a closed-loop of "thinking-action-feedback". In this study, the NN + MM group achieved the highest operational skill score and had the shortest operation time, indicating that this combined model can simultaneously improve the accuracy and proficiency of residents' EVD operations. This is consistent with previous research, which shows that simulated training based on navigation technology can reduce the operation time of novices and improve the success rate of operations [ 20 ]. Cultivating Clinical Thinking and Improving Comprehensive Diagnosis and Treatment Capabilities The core goal of EVD teaching is to cultivate residents' comprehensive ability of "operation based on anatomy and decision-making based on cases". In the combined teaching model, mind maps assist residents in systematically integrating case information, theoretical knowledge, and operational processes to construct a standardized clinical decision - making framework [ 21 ]. For instance, when confronted with a case of acute hydrocephalus with brain shift, residents can utilize mind maps to logically organize the steps of case assessment, puncture path adjustment, and risk prediction. Neuronavigation technology offers a simulated clinical scenario for decision - making practice, enabling residents to adjust the puncture plan according to the simulated brain shift and verify the rationality of the plan through simulated operations. This process aids residents in gradually developing clinical thinking that integrates "assessment-planning-operation-risk management" [ 22 ]. The highest clinical thinking score of the NN + MM group in this study fully validates that the combined model can effectively break the barrier of "disconnection between theory and practice", allowing residents to flexibly apply theoretical knowledge to solve practical clinical problems and significantly enhancing their comprehensive diagnosis and treatment capabilities. Stimulating Learning Interest and Improving Learning Initiative Compared with the conventional indoctrinative teaching model, the combined teaching model of neuronavigation and mind map is more interactive and interesting. It can effectively stimulate residents' learning enthusiasm and initiative. Mind maps transform boring and fragmented theoretical knowledge into visualized and hierarchical diagrams, reducing the difficulty of knowledge understanding and enhancing residents' sense of accomplishment in learning [ 23 ]. Neuronavigation - based simulated operation training allows residents to participate in the operation process independently, rather than passively observing. This satisfies their desire for practical operation and strengthens their learning motivation [ 24 ]. The results of the teaching satisfaction survey in this study showed that the NN + MM group had the highest scores in "learning interest stimulation" (4.7 ± 0.4 points) and the highest overall satisfaction rate (96.43%). This fully indicates that the combined teaching model can improve the learning experience of residents, enable them to change from "passive learning" to "active learning", and ultimately enhance the teaching effect. Limitations of the Study It should be noted that this study has several limitations that need to be addressed in future research. Firstly, this study was a single-center study conducted in a tertiary hospital, and the research subjects were neurosurgical residents in our hospital. This may limit the generalizability of the research results to other levels of hospitals or regions. Secondly, the sample size of this study was relatively small (n = 84). A larger sample size is needed in future studies to verify the stability and reliability of the combined teaching model. Thirdly, the follow-up time of this study was limited to the end of the teaching intervention. It did not evaluate the long-term effect of the combined teaching model on residents' clinical work performance after the end of standardized training. Future studies should conduct long-term follow-up to explore whether the combined teaching model can continuously improve residents' EVD operation level and clinical thinking ability in actual clinical work. Fourthly, this study only compared the combined teaching model with the single mind-map-assisted teaching model and conventional teaching model. It did not compare it with other advanced teaching models (e.g., virtual reality-based teaching, augmented reality-based teaching), which may limit the comprehensiveness of the evaluation of the combined teaching model. Finally, this study did not analyze the influence of individual differences (e.g., learning ability, spatial imagination ability) of residents on the teaching effect. This can be further explored in future studies. Future Research Directions Based on the limitations of this study, several future research directions are proposed. Firstly, multi-center, large-sample randomized controlled trials should be conducted to include neurosurgical residents from different levels of hospitals and regions, aiming to enhance the generalizability of the research results. Secondly, long-term follow-up studies should be designed to monitor the clinical performance of residents in EVD operation and other related clinical work within 1–3 years after the conclusion of the teaching intervention, so as to assess the long-term effect of the combined teaching model. Thirdly, the combined teaching model can be further optimized by integrating other advanced teaching technologies (e.g., virtual reality, augmented reality) to create a more immersive and realistic simulated training environment, thereby further improving the teaching effect. Fourthly, stratified analysis can be performed according to the individual differences of residents, and personalized teaching strategies can be formulated for residents with different learning abilities and spatial imagination abilities, in order to achieve targeted teaching. Finally, qualitative research methods (e.g., in-depth interviews, focus group discussions) can be combined to explore the subjective experiences and suggestions of residents and teachers regarding the combined teaching model, so as to offer more comprehensive evidence for the optimization of the teaching model. Conclusion In conclusion, the combined teaching model of neuronavigation and mind map can effectively overcome the limitations of conventional EVD teaching and single auxiliary teaching models. It can not only strengthen the construction of residents' knowledge systems and improve their mastery of theoretical knowledge but also compensate for the shortage of practical training and enhance their operational skills and clinical thinking abilities. At the same time, this model can stimulate residents' learning interest and improve their learning initiative and teaching satisfaction. Therefore, the combined teaching model of neuronavigation and mind map is an effective optimized strategy for EVD teaching in neurosurgical residency training, which is worthy of popularization and application in clinical teaching. Its widespread application is expected to provide strong support for cultivating high-quality neurosurgical professionals and promoting the development of neurosurgical clinical teaching. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki (2024 revision). It was approved by the Institutional Review Board of Sir Run Run Shaw Hospital (Approval No.: SRRSH-2026-002-15), and all participants signed informed consent forms. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The self-designed questionnaire for teaching satisfaction is available as a supplementary file of this manuscript. Competing interests None. Funding None. Authors' contributions Dajiang Xie designed the study, collected data, performed statistical analysis, drafted the manuscript and revised the manuscript. Trial registration statement This study adheres to the CONSORT guidelines (2025 revision) for reporting randomized controlled trials. A completed CONSORT checklist is provided as an additional file of this manuscript. 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Cabrilo I, Craven CL, Abuhusain H, Pradini-Santos L, Asif H, Marcus HJ, Reddy U, Watkins LD, Toma AK. Neuronavigation-assisted bedside placement of bolt external ventricular drains in the intensive care setting: a technical note. Acta Neurochir (Wien). 2021 Apr;163(4):1127-1133. doi: 10.1007/s00701-020-04634-w. Epub 2020 Oct 31. PMID: 33128621. AlAzri A, Mok K, Chankowsky J, Mullah M, Marcoux J. Placement accuracy of external ventricular drain when comparing freehand insertion to neuronavigation guidance in severe traumatic brain injury. Acta Neurochir (Wien). 2017 Aug;159(8):1399-1411. doi: 10.1007/s00701-017-3201-5. Epub 2017 May 29. PMID: 28555269. Ellens NR, Fischer DL, Meldau JE, Schroeder BA, Patra SE. External Ventricular Drain Placement Accuracy and Safety When Done by Midlevel Practitioners. Neurosurgery. 2019 Jan 1;84(1):235-241. doi: 10.1093/neuros/nyy090. PMID: 29618119.. Todnem N, Nguyen KD, Reddy V, Grogan D, Waitt T, Alleyne CH. A simple and cost-effective model for ventricular catheter placement training: technical note. J Neurosurg. 2020 May 1;134(5):1640-1643. doi: 10.3171/2020.2.JNS19161. PMID: 32357317. Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care. J Neurosci Nurs. 2016 Feb;48(1):54-65. doi: 10.1097/JNN.0000000000000174. PMID: 26720321. Jayasekera BAP, Al-Mousa A, Shtaya A, Pereira E. Freehand external ventricular drain insertion - is there a learning curve? Surg Neurol Int. 2021 Apr 26;12:193. doi: 10.25259/SNI_151_2021. PMID: 34084621; PMCID: PMC8168655. Kirkman MA, Muirhead W, Sevdalis N. The relative efficacy of 3 different freehand frontal ventriculostomy trajectories: a prospective neuronavigation-assisted simulation study. J Neurosurg. 2017 Jan;126(1):304-311. doi: 10.3171/2016.1.JNS152263. Epub 2016 Apr 15. PMID: 27081908.. Cortés Rodriguez F, Krapp LF, Dal Peraro M, Abriata LA. Visualization, Interactive Handling and Simulation of Molecules in Commodity Augmented Reality in Web Browsers Using moleculARweb's Virtual Modeling Kits. Chimia (Aarau). 2022 Feb 23;76(1-2):145-150. doi: 10.2533/chimia.2022.145. PMID: 38069760.. Sonvenso DK, Itikawa EN, Santos MV, Santos LA, Trevisan AC, Bianchin MM, Pitella FA, Kato M, Carlotti CG Jr, Busatto GF, Velasco TR, Santos AC, Leite JP, Sakamoto AC, Machado HR, Nunes AA, Wichert-Ana L. Systematic review of the efficacy in seizure control and safety of neuronavigation in epilepsy surgery: The need for well-designed prospective studies. Seizure. 2015 Sep;31:99-107. doi: 10.1016/j.seizure.2015.07.010. Epub 2015 Jul 23. PMID: 26362385.. Dho YS, Kim YJ, Kim KG, Hwang SH, Kim KH, Kim JW, Kim YH, Choi SH, Park CK. Positional effect of preoperative neuronavigational magnetic resonance image on accuracy of posterior fossa lesion localization. J Neurosurg. 2019 Jul 19;133(2):546-555. doi: 10.3171/2019.4.JNS1989. PMID: 31323639. Nilsson C, Sorensen JL, Konge L, Westen M, Stadeager M, Ottesen B, Bjerrum F. Simulation-based camera navigation training in laparoscopy-a randomized trial. Surg Endosc. 2017 May;31(5):2131-2139. doi: 10.1007/s00464-016-5210-5. Epub 2016 Oct 21. PMID: 27770252; PMCID: PMC5411407. Hu Y, Xiang Y, Lei M, Wu Y, Sun M. The application of mind mapping in the standardized education of inpatient physicians in nephrology. Sci Rep. 2025 Jan 23;15(1):2890. doi: 10.1038/s41598-025-87692-3. PMID: 39843532; PMCID: PMC11754471. Marinho P, Thines L, Verscheure L, Mordon S, Lejeune JP, Vermandel M. Recent advances in cerebrovascular simulation and neuronavigation for the optimization of intracranial aneurysm clipping. Comput Aided Surg. 2012;17(2):47-55. doi: 10.3109/10929088.2011.653403. PMID: 22348657. Yu R, Cheng C, Zhang F. Enhancing competency and self-directed learning in anesthesiology residency: an outcome-based education model integrating online-offline hybrid teaching and mind mapping: a randomized controlled trial. Front Med (Lausanne). 2026 Jan 9;12:1684116. doi: 10.3389/fmed.2025.1684116. PMID: 41585241; PMCID: PMC12827118.. Delgado-Fernández J, Frade-Porto N, Blasco G, Gonzalez-Tarno P, Gil-Simoes R, Pulido P, Sola RG. Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement. J Neurol Surg A Cent Eur Neurosurg. 2021 May;82(3):262-269. doi: 10.1055/s-0040-1715485. Epub 2020 Dec 1. PMID: 33260245. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8783847","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":604614364,"identity":"9449f538-f421-4281-9a5c-6cad774316e4","order_by":0,"name":"Dajiang Xie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYBACxmaGxAcJPDZy/OwNRGphbm94bPBAJs1YsucAkVrYew4+k3xgczhxw40EIrXwzkhOkEjIOcw4c+bjjTcYamyiCWqRnJGWYJBwJp2ZXzqt2ILhWFpuAyEthjNyEhISe6zZJGfnmEkwNhwmrMX+Rv6HA4n/mHkMbp4hUgtjz4HEhgQeZwmDGzzEamlvSGZI4EkzkOwB+iWBGL8AozL95w8em/p+9sMbb3yosSGsBRkYSCSQohyihVQdo2AUjIJRMDIAADmjQ+7geiV1AAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Dajiang","middleName":"","lastName":"Xie","suffix":""}],"badges":[],"createdAt":"2026-02-04 08:39:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8783847/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8783847/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104689526,"identity":"7ec4fe3a-a5ad-4ae1-8874-78d44f2dee58","added_by":"auto","created_at":"2026-03-16 06:00:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6752,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the research design\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8783847/v1/d5f6de4404e3a4b533b32be7.png"},{"id":104784738,"identity":"b6c79629-3415-47e5-b79a-a9c753d6389f","added_by":"auto","created_at":"2026-03-17 08:08:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1185375,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8783847/v1/f21810a7-43b7-4a67-a1fb-ef0ca5d9feaf.pdf"},{"id":104782487,"identity":"a87e55c2-a359-4f37-a5b2-b71c3c3adaad","added_by":"auto","created_at":"2026-03-17 07:57:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":11964,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8783847/v1/a8e9b4124b8305e24fe0df23.docx"},{"id":104782288,"identity":"00e52725-c753-446c-af5f-11f7a8a32f3d","added_by":"auto","created_at":"2026-03-17 07:57:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31714,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8783847/v1/28f77b1e7c2207dec521e6b2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of Neuronavigation Combined with Mind Map in External Ventricular Drainage Teaching for Neurosurgical Residents","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExternal ventricular drainage (EVD) is a fundamental and life-saving emergency procedure in neurosurgery, widely used for the management of acute hydrocephalus, intracerebral hemorrhage, increased intracranial pressure induced by traumatic brain injury, and other critical neurological conditions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This procedure requires high precision in anatomical localization, strict compliance with operational standards, and effective intraoperative risk control, as its success directly affects patient prognosis and long-term functional outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, proficiently performing EVD is recognized as one of the core competencies that neurosurgical residents must acquire during their standardized training, and the quality of EVD teaching is closely related to the cultivation of competent neurosurgical clinicians [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the conventional EVD teaching paradigm for neurosurgical residents is predominantly based on \"theoretical lectures+video demonstrations+bedside observation\", which is associated with notable limitations that hinder the cultivation of competent neurosurgeons [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Firstly, the ventricular system is characterized by a complex deep anatomical structure. The traditional indoctrinative teaching approach fails to help residents construct a three-dimensional cognitive framework of \"skull landmarks-ventricular anatomy-puncture path\", leading to fragmented knowledge retention and inadequate understanding of spatial relationships [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Secondly, clinical practical operation opportunities are extremely limited. EVD puncture involves critical neurovascular structures, and improper manipulation may result in severe complications such as intracerebral hemorrhage, infection, or nerve injury. Therefore, supervisors are often reluctant to allow novice residents to perform independent operations, resulting in insufficient training of operational skills and poor proficiency [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thirdly, the cultivation of clinical thinking is neglected. Conventional teaching primarily focuses on the rote explanation of operational steps, while lacking systematic guidance on how to formulate personalized puncture plans based on individual patient conditions (e.g., ventricular deformation, brain shift) and how to predict and manage intraoperative emergencies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, advances in medical education technology have provided new approaches to address these limitations. Neuronavigation technology, as a precise surgical guidance tool, can accurately reconstruct three-dimensional models of the skull and ventricular system based on CT/MRI images, simulate EVD puncture paths, and provide real-time positioning feedback during simulated operations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This technology effectively helps residents develop spatial positioning capabilities and compensates for the shortage of clinical practical opportunities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the other hand, mind maps, as a visualized knowledge integration tool, can organize scattered knowledge points (including anatomy, operational steps, complication management, and postoperative care) into a hierarchical and logical framework, thereby strengthening the connections between knowledge and improving the efficiency of knowledge internalization [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSingle auxiliary teaching tools, such as neuronavigation or mind maps, have been increasingly applied in neurosurgical teaching, yielding promising results [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, there is a paucity of systematic studies investigating the application effect of their combined use in EVD teaching for neurosurgical residents [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Given the complementary advantages of these two tools-mind maps for knowledge integration and neuronavigation for practical skill enhancement-we hypothesized that their combination would achieve a synergistic effect in EVD teaching. To test this hypothesis, we conducted a three-group controlled trial to explore the application value of the neuronavigation combined with mind map teaching model, aiming to provide empirical evidence for the reform of EVD teaching in neurosurgical residency training and promote the cultivation of high-quality neurosurgical professionals.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Subjects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 84 neurosurgical residents who underwent standardized training at our tertiary hospital from March 2024 to February 2025 were enrolled in this study.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) No prior clinical experience in EVD operation;\u003c/p\u003e\n\u003cp\u003e(2) An educational background of a bachelor\u0026apos;s or master\u0026apos;s degree;\u003c/p\u003e\n\u003cp\u003e(3) Willingness to participate in the study and complete all teaching and assessment procedures.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) Incomplete attendance of teaching courses;\u003c/p\u003e\n\u003cp\u003e(2) Inability to complete the assessment due to personal reasons;\u003c/p\u003e\n\u003cp\u003e(3) Prior training in neuronavigation or mind-map application.\u003c/p\u003e\n\u003cp\u003eThe residents were randomly divided into three groups using a computer - generated random number table: the control group, the mind-map group (MM group), and the neuronavigation+mind-map group (NN+MM group), with 28 residents in each group. This study was approved by the Ethics Committee of our hospital, and all participants signed informed consent forms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeaching Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Neuronavigation system: The StealthStation S7 neuronavigation system (Medtronic, Minneapolis, USA) was utilized in this study. This system can precisely reconstruct high-resolution three-dimensional models of the skull, ventricular system, and adjacent neurovascular structures based on preoperative CT or MRI images. It enables real-time simulation of EVD puncture paths, offers dynamic positioning feedback during simulated operations, and permits repeated practice of puncture techniques without clinical risks.\u003c/p\u003e\n\u003cp\u003e2. Mind map tool: XMind 2023 (XMind Ltd., Shenzhen, China) was employed to construct standardized mind map templates. The teaching team, composed of senior neurosurgeons and medical educators with over 10 years of experience, developed the templates based on the Guidelines for Neurosurgical Operations, authoritative textbooks, and typical clinical cases. The mind maps covered core modules such as cerebral ventricular anatomy, EVD operation indications and contraindications, equipment preparation and inspection, step-by-step puncture procedures, positioning methods, intraoperative complication identification and management, and postoperative care, aiming to assist residents in constructing a systematic and integrated knowledge framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeaching Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll three groups received a total of 40 teaching hours (20 hours for theoretical instruction and 20 hours for practical training), concentrating on the core knowledge and operational skills of EVD. The teaching was conducted by a consistent team of senior neurosurgeons with over 10 years of clinical experience in EVD and teaching expertise, guaranteeing the consistency and standardization of teaching content and quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe control group adopted the conventional teaching model without any auxiliary tools. For theoretical courses, PPT presentations were utilized to explain key knowledge points, including cerebral ventricular anatomy, EVD operation principles, step-by-step procedures, common complications, and their management. For practical courses, standard EVD operation videos were played, and residents were required to observe and take notes. After observation, teachers offered comments and explanations on key operational points, but no simulated operation training or mind - map assistance was arranged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMind Map Group (MM Group)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe MM group received mind-map-assisted teaching based on the conventional teaching model. Three days prior to each theoretical course, standardized mind-map templates and preview tasks were distributed to the residents, guiding them to preview the teaching content and supplement and improve the mind maps in combination with textbooks and teaching materials. During theoretical courses, the mind maps were employed as the main teaching clues to connect theoretical knowledge points, clinical cases, and practical difficulties, enhancing the logical correlation among knowledge. After each course, residents were required to optimize the mind maps according to the classroom content and their own understanding, thus forming personalized learning notes. The teachers reviewed the mind maps one by one and provided targeted feedback to assist residents in improving their knowledge framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeuronavigation\u003c/strong\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003cstrong\u003eMind Map Group (NN\u003c/strong\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003cstrong\u003eMM Group)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe NN+MM group implemented a combined teaching model that integrates mind-map-driven knowledge integration and neuronavigation-based simulated operation. The theoretical teaching part was the same as that of the MM group.\u003c/p\u003e\n\u003cp\u003eFor practical courses, simulated operation training was conducted using the neuronavigation system in combination with mind maps. Before each simulated operation, residents were required to organize the operational process, key nodes (e.g., puncture point selection, angle control, depth determination), and potential risks according to the mind maps. Subsequently, they carried out repeated simulated EVD puncture operations on the neuronavigation system, including equipment calibration, patient positioning, puncture path planning, drainage tube placement, and tube fixation. During the simulated operations, teachers disassembled and explained operational difficulties and common errors in combination with the mind maps, guiding residents to correct their mistakes promptly.\u003c/p\u003e\n\u003cp\u003eAfter each practical course, residents reviewed the simulated operation process using the mind maps, marked their operational errors and areas for improvement, and formed a closed-loop teaching process of \u0026quot;theoretical learning-mind map integration - simulated operation practice-review and optimization\u0026quot;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Design Flow Chart\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo clearly illustrate the entire process of resident enrollment, grouping, teaching implementation, and outcome assessment, a flow chart was constructed, as shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e Flow chart of the research design\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheoretical Assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA standardized closed-book examination was conducted to assess residents\u0026apos; mastery of theoretical knowledge. The examination paper consisted of 30 single-choice questions (1 point each, total 30 points), 10 multiple-choice questions (2 points each, total 20 points), and 3 case analysis questions (total 50 points), with a full score of 100 points. The examination content focused on key knowledge points, including cerebral ventricular anatomy, EVD operation indications and contraindications, equipment principles and inspection methods, puncture positioning techniques, intraoperative complication identification and management, and postoperative care.\u003c/p\u003e\n\u003cp\u003eThe examination papers were graded by two independent senior neurosurgeons in a blind manner, and the average score was taken as the final theoretical assessment score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical Thinking Scoring\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree complex clinical cases were selected to evaluate the residents\u0026apos; clinical thinking ability, encompassing acute hydrocephalus secondary to intracerebral hemorrhage, traumatic hydrocephalus with brain shift, and infected hydrocephalus. The residents were required to independently formulate individualized EVD puncture plans, analyze potential intraoperative risks, and propose corresponding emergency management strategies within a specified time frame.\u003c/p\u003e\n\u003cp\u003eThe scoring was carried out from four dimensions: case assessment and diagnosis (25 points), rationality of the puncture plan (25 points), risk prediction and prevention (25 points), and emergency handling capacity (25 points), with a full score of 100 points. Two senior neurosurgeons with extensive clinical experience conducted independent blind scoring, and the average score was adopted as the final clinical thinking score.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eO\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eperational skill assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe operational skill assessment was carried out using the internationally recognized EVD skill scoring system [6], with minor adjustments made to suit the simulated operation scenario. Quantitative scoring was carried out across 10 dimensions: equipment preparation and inspection (10 points), compliance with sterile operation (10 points), accuracy of patient positioning (10 points), precision of puncture point marking (10 points), control of puncture angle (15 points), mastery of puncture depth (15 points), accuracy of drainage tube placement (10 points), standardization of tube fixation (10 points), awareness of radiation protection (5 points), and overall operational standardization (5 points), with a full score of 100 points. Two experienced neurosurgeons conducted independent assessments blindly, and the average score was taken as the final operational skill score. Meanwhile, the time taken for each resident to complete the full-process simulated EVD operation was recorded to evaluate operational proficiency (a shorter time indicates higher proficiency).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTeaching Satisfaction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA self-designed Likert 5-point scale questionnaire(see Additional file 1 for the English version)\u0026nbsp;was employed to assess residents\u0026apos; satisfaction with the teaching model. Scores on the questionnaire ranged from 1 (extremely dissatisfied) to 5 (extremely satisfied).\u003c/p\u003e\n\u003cp\u003eThe questionnaire consisted of four evaluation dimensions: knowledge understanding and mastery (1-5 points), improvement in operational skills (1-5 points), stimulation of learning interest (1-5 points), and cultivation of clinical thinking (1-5 points), with a total score of 20 points. A total score of \u0026ge;16 points (i.e., an average score of\u0026ge;4 points per dimension) was defined as satisfactory.\u003c/p\u003e\n\u003cp\u003eThe teaching satisfaction rate was calculated as the proportion of residents who achieved a total score of\u0026ge;16 points. The questionnaire had a Cronbach\u0026apos;s \u0026alpha; coefficient of 0.87, which indicated good reliability and validity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS 26.0 statistical software (IBM Corp., Armonk, USA) was used for data analysis. Measurement data were presented as mean\u0026plusmn;standard deviation (x\u0026plusmn;s). Inter-group comparisons for measurement data were carried out using one-way analysis of variance (ANOVA), followed by Bonferroni post-hoc tests for pairwise comparisons. Count data were presented as rates (%), and inter-group comparisons for count data were performed using the \u0026chi;\u0026sup2; test. A P\u0026lt;0.05 was regarded as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Baseline Data of Residents\u003c/h2\u003e \u003cp\u003eThe three groups of residents were comparable in terms of baseline characteristics, including gender composition, average age, educational background distribution, and clinical work duration (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This ensured the objectivity and reliability of subsequent teaching interventions and outcome comparisons. The detailed baseline data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline characteristics among the three groups of neurosurgical residents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e(Male/Female, n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEducational Background(n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical Work Duration\u003c/p\u003e \u003cp\u003e(x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBachelor's Degree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster's Degree\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (60.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (39.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (64.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNN\u0026thinsp;+\u0026thinsp;MM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/χ\u0026sup2; Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: There were no statistically significant differences in all baseline characteristics among the three groups (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating good comparability. None of the residents had a doctoral degree or prior EVD-related operational experience; clinical work duration refers to the total length of clinical practice after graduation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Theoretical Assessment and Clinical Thinking Scores\u003c/h2\u003e \u003cp\u003eThe results of theoretical assessment and clinical thinking scoring showed a consistent trend: the NN\u0026thinsp;+\u0026thinsp;MM group achieved significantly higher scores in both indicators than the MM group and the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the MM group exhibited significantly higher scores than the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These findings suggest that both the combined teaching model and the single mind-map-assisted teaching model are superior to the conventional teaching model in promoting residents' theoretical mastery and clinical thinking development, and the combined model yields the most favorable effect. Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of theoretical assessment and clinical thinking scores among the three groups (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, points)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample Size(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheoretical Assessment Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Thinking Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.58\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.15\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNN\u0026thinsp;+\u0026thinsp;MM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Compared with the control group, *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; compared with the MM group, #P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Bonferroni post-hoc test).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Operational Skill Assessment Results\u003c/h2\u003e \u003cp\u003eCombined analysis of operational skill scores and assessment duration revealed that the NN\u0026thinsp;+\u0026thinsp;MM group outperformed both the MM group and the control group in both aspects: it achieved the highest operational skill score and the shortest assessment duration (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The MM group also demonstrated better performance than the control group in terms of both operational skill score and assessment duration (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These results indicate that the combined teaching model can significantly enhance both the operational accuracy (higher score) and proficiency (shorter time) of neurosurgical residents in EVD. Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of operational skill assessment results among the three groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample Size(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssessment Duration\u003c/p\u003e \u003cp\u003e(x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOperational Skill Score\u003c/p\u003e \u003cp\u003e(x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, points)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNN\u0026thinsp;+\u0026thinsp;MM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Compared with the control group, *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; compared with the MM group, #P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Bonferroni post-hoc test); shorter assessment duration indicates higher operational proficiency.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Teaching Satisfaction\u003c/h2\u003e \u003cp\u003eThe results of the teaching satisfaction survey indicated that the teaching satisfaction rate of the NN\u0026thinsp;+\u0026thinsp;MM group (96.43%) was significantly higher than those of the MM group (85.71%) and the control group (67.86%) (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In terms of each evaluation dimension, the average score of the NN\u0026thinsp;+\u0026thinsp;MM group was also the highest, followed by those of the MM group and the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This trend is consistent with the results of theoretical, operational, and clinical thinking assessments, confirming the advantage of the combined teaching model in enhancing residents' learning experience and satisfaction. Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of teaching satisfaction among the three groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfactory Cases(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSatisfaction Rate(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnowledge Understanding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSkill Improvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInterest Stimulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThinking Cultivation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.71*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNN\u0026thinsp;+\u0026thinsp;MM Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.43*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2;/F Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: Compared with the control group, *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; compared with the MM group, #P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the satisfaction rate was calculated based on a total questionnaire score of \u0026ge;\u0026thinsp;16 points; data for the four dimensions are expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s (points).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCurrent Status and Challenges of EVD Teaching for Neurosurgical Residents\u003c/h2\u003e \u003cp\u003eAs a core and basic procedure in neurosurgery, EVD plays a crucial role in the management of critical neurological diseases. Its proficient mastery is essential for neurosurgical residents to transition from trainees to independent clinicians [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the current EVD teaching for neurosurgical residents faces multiple challenges that limit the quality of training. Firstly, the anatomical basis of EVD is complex. The ventricular system is located deep within the brain, and its spatial position and adjacent neurovascular relationships are difficult to visualize through traditional two - dimensional teaching materials (e.g., PPT, textbooks). This leads to inadequate understanding of puncture paths and positioning techniques among residents [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Secondly, practical training is severely insufficient. Due to the high risk of EVD operation, clinical patients cannot be used as training objects for novice residents. The lack of effective simulated training platforms results in insufficient operational experience and poor proficiency [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thirdly, clinical thinking ability is weak. In conventional teaching, residents are accustomed to passively accepting knowledge, lacking the ability to integrate theoretical knowledge with clinical practice. This makes it difficult for them to formulate personalized operation plans and handle emergencies when facing complex clinical cases [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Fourthly, learning enthusiasm is low. The traditional indoctrinative teaching model is boring and fragmented, failing to stimulate residents' learning interest, which leads to low learning efficiency and poor knowledge retention [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These challenges highlight the urgent need to optimize the EVD teaching model for neurosurgical residents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSynergistic Advantages of the Combined Teaching Model of Neuronavigation and Mind Map\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eStrengthening Knowledge System Construction and Improving Theoretical Mastery\u003c/h2\u003e \u003cp\u003eThe core advantage of mind maps in EVD teaching lies in their capacity to integrate scattered knowledge points into a systematic and visualized hierarchical framework [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Through visualization, by establishing logical connections among cerebral ventricular anatomy, operational steps, complication management, and other core knowledge points, mind maps assist residents in avoiding fragmented memory and constructing a comprehensive knowledge system [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The results of this study indicated that the theoretical score of the MM group was significantly higher than that of the control group, confirming that mind maps can effectively enhance the efficiency of knowledge internalization.\u003c/p\u003e \u003cp\u003eOn this basis, the NN\u0026thinsp;+\u0026thinsp;MM group combined neuronavigation technology to transform abstract anatomical knowledge into intuitive three-dimensional models and immersive simulated operation experiences [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. During simulated operations, residents can observe the spatial relationship between the puncture path and the ventricular system in real - time, which further deepens their understanding of theoretical knowledge and promotes the transformation of knowledge from \"passive memory\" to \"active application\" [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, the NN\u0026thinsp;+\u0026thinsp;MM group achieved the highest theoretical score, which is consistent with previous findings that the combination of visualization tools and simulated training can significantly improve the theoretical mastery of medical students [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCompensating for Practical Shortcomings and Enhancing Operational Skills\u003c/h2\u003e \u003cp\u003eNeuronavigation technology provides a safe, controllable, and repeatable simulated training platform[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It allows residents to conduct repeated puncture training without the risk of harming patients. Through real-time positioning feedback, residents can promptly correct operational errors, gradually master key skills such as puncture point selection, angle control, and depth grasp, and develop muscle memory and spatial positioning ability [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The synergistic effect of \"mind map+neuronavigation\" is the key to enhancing operational skills. Mind maps clarify the operational process and key nodes, helping residents avoid blind operations. Simulated operations based on neuronavigation verify and reinforce the key points in mind maps, forming a closed-loop of \"thinking-action-feedback\". In this study, the NN\u0026thinsp;+\u0026thinsp;MM group achieved the highest operational skill score and had the shortest operation time, indicating that this combined model can simultaneously improve the accuracy and proficiency of residents' EVD operations. This is consistent with previous research, which shows that simulated training based on navigation technology can reduce the operation time of novices and improve the success rate of operations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eCultivating Clinical Thinking and Improving Comprehensive Diagnosis and Treatment Capabilities\u003c/h2\u003e \u003cp\u003eThe core goal of EVD teaching is to cultivate residents' comprehensive ability of \"operation based on anatomy and decision-making based on cases\".\u003c/p\u003e \u003cp\u003eIn the combined teaching model, mind maps assist residents in systematically integrating case information, theoretical knowledge, and operational processes to construct a standardized clinical decision - making framework [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For instance, when confronted with a case of acute hydrocephalus with brain shift, residents can utilize mind maps to logically organize the steps of case assessment, puncture path adjustment, and risk prediction.\u003c/p\u003e \u003cp\u003eNeuronavigation technology offers a simulated clinical scenario for decision - making practice, enabling residents to adjust the puncture plan according to the simulated brain shift and verify the rationality of the plan through simulated operations. This process aids residents in gradually developing clinical thinking that integrates \"assessment-planning-operation-risk management\" [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe highest clinical thinking score of the NN\u0026thinsp;+\u0026thinsp;MM group in this study fully validates that the combined model can effectively break the barrier of \"disconnection between theory and practice\", allowing residents to flexibly apply theoretical knowledge to solve practical clinical problems and significantly enhancing their comprehensive diagnosis and treatment capabilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eStimulating Learning Interest and Improving Learning Initiative\u003c/h2\u003e \u003cp\u003eCompared with the conventional indoctrinative teaching model, the combined teaching model of neuronavigation and mind map is more interactive and interesting. It can effectively stimulate residents' learning enthusiasm and initiative. Mind maps transform boring and fragmented theoretical knowledge into visualized and hierarchical diagrams, reducing the difficulty of knowledge understanding and enhancing residents' sense of accomplishment in learning [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Neuronavigation - based simulated operation training allows residents to participate in the operation process independently, rather than passively observing. This satisfies their desire for practical operation and strengthens their learning motivation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of the teaching satisfaction survey in this study showed that the NN\u0026thinsp;+\u0026thinsp;MM group had the highest scores in \"learning interest stimulation\" (4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 points) and the highest overall satisfaction rate (96.43%). This fully indicates that the combined teaching model can improve the learning experience of residents, enable them to change from \"passive learning\" to \"active learning\", and ultimately enhance the teaching effect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eLimitations of the Study\u003c/h2\u003e \u003cp\u003eIt should be noted that this study has several limitations that need to be addressed in future research. Firstly, this study was a single-center study conducted in a tertiary hospital, and the research subjects were neurosurgical residents in our hospital. This may limit the generalizability of the research results to other levels of hospitals or regions. Secondly, the sample size of this study was relatively small (n\u0026thinsp;=\u0026thinsp;84). A larger sample size is needed in future studies to verify the stability and reliability of the combined teaching model. Thirdly, the follow-up time of this study was limited to the end of the teaching intervention. It did not evaluate the long-term effect of the combined teaching model on residents' clinical work performance after the end of standardized training. Future studies should conduct long-term follow-up to explore whether the combined teaching model can continuously improve residents' EVD operation level and clinical thinking ability in actual clinical work. Fourthly, this study only compared the combined teaching model with the single mind-map-assisted teaching model and conventional teaching model. It did not compare it with other advanced teaching models (e.g., virtual reality-based teaching, augmented reality-based teaching), which may limit the comprehensiveness of the evaluation of the combined teaching model. Finally, this study did not analyze the influence of individual differences (e.g., learning ability, spatial imagination ability) of residents on the teaching effect. This can be further explored in future studies.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research Directions\u003c/h2\u003e \u003cp\u003eBased on the limitations of this study, several future research directions are proposed. Firstly, multi-center, large-sample randomized controlled trials should be conducted to include neurosurgical residents from different levels of hospitals and regions, aiming to enhance the generalizability of the research results. Secondly, long-term follow-up studies should be designed to monitor the clinical performance of residents in EVD operation and other related clinical work within 1\u0026ndash;3 years after the conclusion of the teaching intervention, so as to assess the long-term effect of the combined teaching model. Thirdly, the combined teaching model can be further optimized by integrating other advanced teaching technologies (e.g., virtual reality, augmented reality) to create a more immersive and realistic simulated training environment, thereby further improving the teaching effect. Fourthly, stratified analysis can be performed according to the individual differences of residents, and personalized teaching strategies can be formulated for residents with different learning abilities and spatial imagination abilities, in order to achieve targeted teaching. Finally, qualitative research methods (e.g., in-depth interviews, focus group discussions) can be combined to explore the subjective experiences and suggestions of residents and teachers regarding the combined teaching model, so as to offer more comprehensive evidence for the optimization of the teaching model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the combined teaching model of neuronavigation and mind map can effectively overcome the limitations of conventional EVD teaching and single auxiliary teaching models. It can not only strengthen the construction of residents' knowledge systems and improve their mastery of theoretical knowledge but also compensate for the shortage of practical training and enhance their operational skills and clinical thinking abilities. At the same time, this model can stimulate residents' learning interest and improve their learning initiative and teaching satisfaction.\u003c/p\u003e \u003cp\u003eTherefore, the combined teaching model of neuronavigation and mind map is an effective optimized strategy for EVD teaching in neurosurgical residency training, which is worthy of popularization and application in clinical teaching. Its widespread application is expected to provide strong support for cultivating high-quality neurosurgical professionals and promoting the development of neurosurgical clinical teaching.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki (2024 revision). It was approved by the Institutional Review Board of Sir Run Run Shaw Hospital (Approval No.: SRRSH-2026-002-15), and all participants signed informed consent forms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The self-designed questionnaire for teaching satisfaction is available as a supplementary file of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDajiang Xie designed the study, collected data, performed statistical analysis, drafted the manuscript and revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrial registration statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adheres to the CONSORT guidelines (2025 revision) for reporting randomized controlled trials. A completed CONSORT checklist is provided as an additional file of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaum GR, Hooten KG, Lockney DT, Fargen KM, Turan N, Pradilla G, Murad GJA, Harbaugh RE, Glantz M; EVD Best Practice Team. External ventricular drain practice variations: results from a nationwide survey. J Neurosurg. 2017 Nov;127(5):1190-1197. doi: 10.3171/2016.9.JNS16367. Epub 2017 Jan 13. PMID: 28084912.\u003c/li\u003e\n\u003cli\u003eChung DY, Olson DM, John S, Mohamed W, Kumar MA, Thompson BB, Rordorf GA. Evidence-Based Management of External Ventricular Drains. Curr Neurol Neurosci Rep. 2019 Nov 26;19(12):94. doi: 10.1007/s11910-019-1009-9. 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A simple and cost-effective model for ventricular catheter placement training: technical note. J Neurosurg. 2020 May 1;134(5):1640-1643. doi: 10.3171/2020.2.JNS19161. PMID: 32357317. \u003c/li\u003e\n\u003cli\u003eHepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care. J Neurosci Nurs. 2016 Feb;48(1):54-65. doi: 10.1097/JNN.0000000000000174. PMID: 26720321.\u003c/li\u003e\n\u003cli\u003eJayasekera BAP, Al-Mousa A, Shtaya A, Pereira E. Freehand external ventricular drain insertion - is there a learning curve? Surg Neurol Int. 2021 Apr 26;12:193. doi: 10.25259/SNI_151_2021. PMID: 34084621; PMCID: PMC8168655.\u003c/li\u003e\n\u003cli\u003eKirkman MA, Muirhead W, Sevdalis N. The relative efficacy of 3 different freehand frontal ventriculostomy trajectories: a prospective neuronavigation-assisted simulation study. J Neurosurg. 2017 Jan;126(1):304-311. doi: 10.3171/2016.1.JNS152263. Epub 2016 Apr 15. PMID: 27081908..\u003c/li\u003e\n\u003cli\u003eCort\u0026eacute;s Rodriguez F, Krapp LF, Dal Peraro M, Abriata LA. Visualization, Interactive Handling and Simulation of Molecules in Commodity Augmented Reality in Web Browsers Using moleculARweb\u0026apos;s Virtual Modeling Kits. Chimia (Aarau). 2022 Feb 23;76(1-2):145-150. doi: 10.2533/chimia.2022.145. PMID: 38069760..\u003c/li\u003e\n\u003cli\u003eSonvenso DK, Itikawa EN, Santos MV, Santos LA, Trevisan AC, Bianchin MM, Pitella FA, Kato M, Carlotti CG Jr, Busatto GF, Velasco TR, Santos AC, Leite JP, Sakamoto AC, Machado HR, Nunes AA, Wichert-Ana L. Systematic review of the efficacy in seizure control and safety of neuronavigation in epilepsy surgery: The need for well-designed prospective studies. Seizure. 2015 Sep;31:99-107. doi: 10.1016/j.seizure.2015.07.010. Epub 2015 Jul 23. 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PMID: 39843532; PMCID: PMC11754471.\u003c/li\u003e\n\u003cli\u003eMarinho P, Thines L, Verscheure L, Mordon S, Lejeune JP, Vermandel M. Recent advances in cerebrovascular simulation and neuronavigation for the optimization of intracranial aneurysm clipping. Comput Aided Surg. 2012;17(2):47-55. doi: 10.3109/10929088.2011.653403. PMID: 22348657.\u003c/li\u003e\n\u003cli\u003eYu R, Cheng C, Zhang F. Enhancing competency and self-directed learning in anesthesiology residency: an outcome-based education model integrating online-offline hybrid teaching and mind mapping: a randomized controlled trial. Front Med (Lausanne). 2026 Jan 9;12:1684116. doi: 10.3389/fmed.2025.1684116. PMID: 41585241; PMCID: PMC12827118..\u003c/li\u003e\n\u003cli\u003eDelgado-Fern\u0026aacute;ndez J, Frade-Porto N, Blasco G, Gonzalez-Tarno P, Gil-Simoes R, Pulido P, Sola RG. Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement. 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PMID: 33260245.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neuronavigation, Mind map, External ventricular drainage, Neurosurgical residents, Teaching model, Standardized training","lastPublishedDoi":"10.21203/rs.3.rs-8783847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8783847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eExternal ventricular drainage (EVD) is a core emergency procedure in neurosurgery, and proficiently mastering this technique is essential for neurosurgical residents during standardized training. This study aimed to explore the application value of a combined teaching model of neuronavigation and mind map in EVD training for neurosurgical residents and to provide empirical evidence to optimize the teaching paradigm of neurosurgical practical skills.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEighty-four neurosurgical residents without prior clinical experience in EVD, who received standardized training at our hospital from March 2024 to February 2025, were enrolled as research subjects. They were randomly divided into three groups using a computer-generated random number table: the control group, the mind map (MM) group, and the neuronavigation+mind map (NN\u0026thinsp;+\u0026thinsp;MM) group, with 28 residents in each group. The control group adopted the conventional teaching method (theoretical lectures+video demonstrations+bedside observation). The MM group received mind map-assisted teaching on the basis of conventional teaching. The NN\u0026thinsp;+\u0026thinsp;MM group implemented a combined teaching model integrating neuronavigation-based simulated operation and mind map-driven knowledge system construction. After the completion of teaching, the teaching effect was comprehensively evaluated using four indicators: theoretical assessment (closed-book examination), operational skill assessment (simulated operation with time recording), clinical thinking scoring (case analysis), and teaching satisfaction questionnaire. Statistical analysis was performed using SPSS 26.0 software, with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe NN\u0026thinsp;+\u0026thinsp;MM group exhibited significantly higher scores in theoretical assessment (90.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86 vs. 83.15\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78 and 76.58\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92), operational skill assessment (91.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52 vs. 82.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35 and 74.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07), and clinical thinking assessment (89.64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98 vs. 81.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26 and 73.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.89), as well as a higher teaching satisfaction rate (96.43% vs. 85.71% and 67.86%), when compared with the MM group and the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, all evaluation indicators of the MM group were significantly superior to those of the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe combined teaching model of neuronavigation and mind map can significantly enhance neurosurgical residents' mastery of theoretical knowledge, operational proficiency, and clinical thinking ability during EVD training. Compared with single mind map-assisted teaching and conventional teaching, this combined model yields better teaching outcomes and higher resident satisfaction. It serves as an effective optimized strategy for EVD teaching in neurosurgical residency training. Its application is expected to provide strong support for cultivating high-quality neurosurgical professionals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChinese Clinical Trial Registry (ChiCTR); ChiCTR2500098765; Registered on 15 March 2025; Retrospectively registered.\u003c/p\u003e","manuscriptTitle":"Application of Neuronavigation Combined with Mind Map in External Ventricular Drainage Teaching for Neurosurgical Residents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 06:00:42","doi":"10.21203/rs.3.rs-8783847/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-26T09:37:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T14:44:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T10:01:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147513640308482668642204388702081187757","date":"2026-03-21T09:57:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T21:13:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103377787118577634129268168349502736378","date":"2026-03-20T21:06:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329801599320255181115541843330050417249","date":"2026-03-20T03:05:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186558575205651685498171572863983621908","date":"2026-03-19T03:21:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318244827576182313774551902197501008432","date":"2026-03-18T18:39:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-11T17:25:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281584466822612556546417032049709931988","date":"2026-03-11T17:19:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-11T09:28:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T07:34:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T10:32:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T09:05:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-02-10T08:32:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6790a913-041f-4c84-a6ac-3fe744e534ec","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T06:00:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 06:00:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8783847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8783847","identity":"rs-8783847","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}