Introduction

Intracerebral hemorrhage (ICH), characterised as a primary, spontaneous, and non-traumatic form of stroke, constitutes a significant public health challenge due to its swift onset, progression, and elevated morbidity and mortality rates1,2,3. Comprising 12–20% of all strokes globally4, ICH presents considerable difficulties in medical management and surgical intervention5. While traditional surgical techniques have shown efficacy, they are often associated with substantial risks and limitations. Notably, manual CT-guided puncture and drainage procedures frequently result in inaccurate placement of the drainage tube within the centre of the haematoma cavity, leading to inadequate clot removal and heightened complications6,7.

To overcome these limitations, the advent of 3D imaging fusion techniques and 3D-printed surgical guide plates heralds a significant advancement, offering bespoke solutions tailored to the individual patient’s anatomy. These innovations ensure precise puncture pathways, facilitating accurate drainage tube positioning and efficient haematoma evacuation, thus enhancing haematoma clearance rates and diminishing intraoperative risks8,9. The main indications for 3D-printed guide plate-guided puncture and drainage include deep-seated spontaneous intracerebral hemorrhages, particularly those in the basal ganglia and thalamus, as well as intraventricular hemorrhage with cast formation and obstructive hydrocephalus6,10. Absolute contraindications encompass concomitant vascular malformations or aneurysms, in which puncture carries a high risk of catastrophic rebleeding11,12. Patients in the late stage of cerebral herniation or with unstable vital signs are also generally unsuitable for this procedure13. Regarding timing, existing evidence suggests that hematoma evacuation within 24 h is associated with improved outcomes14. Given that the preparation of a guide plate typically requires 0.5–3 h, the process remains compatible with the therapeutic window and may reduce transfer delays for patients treated in secondary hospitals. Surgical performance and outcomes reported in recent studies have demonstrated shorter operative times, higher hematoma clearance rates, lower complication rates, and reduced postoperative hospitalization compared with traditional craniotomy7,15. Furthermore, 3D-printed guide plates have been safely applied even in high-risk cases such as brainstem hemorrhage, with clearance rates exceeding 90% and no puncture-related complications10. Collectively, these findings highlight the practicality, precision, and safety of this minimally invasive approach.

Despite these compelling advantages and its high suitability for widespread use, particularly in secondary or resource-limited hospitals, the clinical translation rate of 3D-printing technology in neurosurgery remains relatively low. This discrepancy raises a critical question: does this limited uptake stem from inherent technical barriers, or from insufficient preparedness among the end-users? This suggests that the bottleneck may not lie within the technology itself, but with the neurosurgeons who are central to its adoption. Neurosurgeons, pivotal in the management of intracerebral haemorrhages, play a crucial role in evaluating the integration of 3D-printed guide plates into surgical protocols. Their expertise, experience, and viewpoints are essential for gauging the adoption and effectiveness of these innovative instruments. The Knowledge, Attitude, and Practices (KAP) survey serves as a diagnostic research instrument, shedding light on a group’s understanding, perceptions, and behaviours concerning specific topics, especially within health literacy. This tool is predicated on the notion that knowledge informs attitudes, which, in turn, influence behaviours16,17,18. In the realm of neurosurgical practice, the KAP framework is invaluable for elucidating and improving healthcare outcomes, assessing the knowledge base, attitudes towards particular practices or technologies, and their actual application in clinical environments. Across various medical disciplines, KAP studies have uncovered knowledge deficits, reluctance towards novel practices, and obstacles to adopting cutting-edge technologies. Nonetheless, there exists a notable paucity of KAP research focused on neurosurgeons’ engagement with 3D-printed guide plates, particularly in the context of puncture and drainage surgeries for ICH. This research gap is particularly significant in the context of China, where clinical studies have highlighted low cost and high precision as advantages that make 3D-printed guide plates particularly suitable for widespread adoption in resource-limited hospitals6. By contrast, reports from other countries have mainly emphasized the technical feasibility and training potential of 3D-printed navigation molds and models15. This distinction underscores that the barriers and drivers for adoption may differ significantly across healthcare systems, warranting a context-specific investigation.

Therefore, this study seeks to bridge this research gap, exploring neurosurgeons’ knowledge, attitudes, and practices pertaining to these guide plates, thereby underscoring the importance of this technology in refining surgical interventions for ICH treatment.

Methods

Study design and participants

This online cross-sectional study was conducted from 15 November to 30 December 2023 in China, with neurosurgeons as the target participant group. Ethical clearance was secured from the Ethics Committee of Hangzhou Medical College (Approval No: LL2023-07), and informed consent was duly obtained from all participants. We confirmed that all experiments were performed in accordance with relevant guidelines and regulations. The inclusion criteria were as follows: (1) Current practice as a neurosurgeon; (2) Voluntary agreement to participate in the survey upon providing informed consent. The exclusion criteria included: (1) Incomplete questionnaire submissions; (2) Questionnaire completion times of less than 90 s or more than 1800 s. This time range was determined based on the number of questionnaire questions, previous literature, and feedback from pre-experiment participants. a completion time of less than 90 s was deemed insufficient for careful reading and thoughtful response, suggesting potential inattentive participation. Conversely, completion times exceeding 1800 s (30 min) were excluded to minimize bias from potential interruptions or the use of external resources during completion, which could compromise the spontaneity and validity of the responses.

The survey questionnaire was designed and disseminated using Wenjuanxing, enabling the generation of a unique survey link and an associated QR code. This link or QR code was distributed to 12 neurosurgery groups via WeChat, encompassing members from hospitals throughout various provinces nationwide. The participants accessed the questionnaire by scanning the QR code and provided their responses. The responses from the collected questionnaires were meticulously compiled and analysed.

Questionnaire introduction

The design of the questionnaire was informed by relevant guidelines and existing literature within the field. It was subsequently refined based on feedback from four neurosurgery experts, leading to several amendments. A pilot study was then conducted with an initial participant cohort of 81 individuals. Feedback from this preliminary phase demonstrated a high level of internal consistency, as reflected by a Cronbach’s alpha coefficient of 0.958. This coefficient was broken down further into 0.973 for the knowledge dimension, 0.948 for the attitude dimension, and 0.946 for the practice dimension.

The finalised questionnaire was divided into four sections (appendix): demographic details, knowledge, attitude, and practice dimensions. The knowledge section consisted of 16 questions, with scores ranging from 16 to 48 points, where a score of 3 signified comprehensive understanding, 2 indicated basic familiarity, and 1 represented a lack of understanding. The attitude section included 8 questions, utilising a five-point Likert scale ranging from very positive (5 points) to very negative (1 point), resulting in a total scoring range of 8 to 40 points. Similarly, the practice section comprised 8 questions, employing a five-point Likert scale from always (5 points) to never (1 point), also yielding a total scoring range of 8 to 40 points. Scores exceeding 70% of the maximum possible in each dimension were deemed indicative of sufficient knowledge, a positive attitude, and proactive practice behaviours19.

Statistical analysis

Data analysis was performed using SPSS version 22.0 (IBM, Armonk, NY, USA). Continuous data are presented as the median, 25th percentile, and 75th percentile, whereas categorical data are expressed in terms of number and percentage (n%). Continuous variables were subjected to a normality assessment, employing the t-test for data following a normal distribution and the Wilcoxon Mann-Whitney test for data not normally distributed when comparing two groups. For comparisons among three or more groups with normally distributed continuous variables and homogenous variance, ANOVA was utilised, while the Kruskal-Wallis test was applied to non-normally distributed data. In the multivariate analysis, the median score served as the cut-off value. Univariate variables with a P-value less than 0.05 were considered for inclusion in the multivariate regression analysis. Structural equation modelling (SEM) was employed to examine the interrelations among knowledge (K), attitude (A), and practice (P). A P-value of less than 0.05, on a two-sided basis, was considered statistically significant.

Results

A total of 230 questionnaires were collected, from which exclusions were made for (1) non-participation in questionnaire completion (2 cases) and (2) completion times of less than 90 s or exceeding 1800 s (5 cases), resulting in 223 valid responses. Analysis of the formal experiment feedback revealed a total Cronbach’s α coefficient of 0.960, with Cronbach’s α for the knowledge dimension at 0.972, for the attitude dimension at 0.941, and for the practice dimension at 0.948; the Kaiser-Meyer-Olkin (KMO) value was 0.932. Amongst the participants, 175 (78.5%) were male, with a median age of 40 years (interquartile range: 34, 45), 160 (71.7%) possessed a Bachelor’s degree or lower, 93 (41.7%) held a senior professional title, 87 (39.0%) had more than 15 years of professional experience, 120 (53.8%) had undergone training in puncture and drainage surgery for ICH guided by a 3D-printed guide plate, and 137 (61.4%) had not employed puncture and drainage surgery for ICH using a 3D-printed guide plate. The median scores (25th percentile, 75th percentile) for knowledge (possible range: 16–48), attitude (possible range: 8–40), and practice (possible range: 8–40) were 37 (32, 47), 37 (32, 40), and 24 (17, 32) respectively. Neurosurgeons from different hospital grades, with varying years of work experience, participation in training related to puncture and drainage surgery for ICH guided by 3D-printed guide plates, application of such surgery, and the number of surgical cases guided by 3D-printed guide plates were found to have significantly different scores in knowledge, attitude, and practice. Moreover, variations in knowledge scores were more pronounced among participants of different gender, age, and professional titles. Similarly, practice scores varied significantly with age (all P < 0.05) (Table 1).

Table 1 Basic information of participants and KAP score.
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Professional title: In China, professional titles for physicians are hierarchical. In this study, they were categorized as: None (residents in training), Junior (Attending Physician), Intermediate (Associate Chief Physician), and Senior (Chief Physician).

Hospital grade: Secondary hospitals provide regional medical services with some teaching/research responsibilities, while tertiary hospitals (Grade A and B) offer high−level specialized medical care and advanced teaching/research functions.

The distribution of knowledge dimensions shown that the two questions with the highest proportion choosing the “very familiar” option were “During the design of the puncture path, it is essential to avoid critical intracranial structures. Typically, the puncture is performed along the long axis of the hematoma, with adjustments made based on the hematoma’s specific location.” (K7) with 56.5% and “When identifying the puncture entry point, it is crucial to first determine the hematoma’s projection on the body surface and locate the center of the hematoma projection.” (K6) with 50.2%. On the other hand, the two questions with the highest proportion choosing the “heard about” option were “In the field of medical 3D printing, the process primarily involves three-dimensional reconstruction based on imaging data, such as CT scans. Various materials, including metals, polymers, and photosensitive resins, are used to construct solid objects layer by layer.” (K1) with 54.3% and “Commonly used medical 3D reconstruction software includes 3D Slicer, Mimics, E3D, among others.” (K3) with 49.8% (Table 2).

Table 2 Knowledge dimension of the participants.
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Table 3 Attitude dimension of the participants.
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Table 4 Practice dimension of the participants.
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Table 5 Correlation analysis of KAP scores.
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Table 6 Univariable and multivariable logistic regression.
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Table 7 The fit indices of the structural equation model (SEM) before and after model adjustment.
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Fig. 1
figure 1

The structural equation model (SEM) before and after model adjustment. Rectangle shows observed variables, ellipses indicate potential variables, and circles represent residual terms.

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Table 8 Bootstrap analysis of mediating effect significance test for the final mode.
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Discussion

Neurosurgeons demonstrated adequate knowledge and positive attitudes but showed a lack of active engagement in employing 3D-printed guide plates for the puncture and drainage surgeries in intracerebral haemorrhage. To enhance clinical practices, it is advisable that educational programmes and training opportunities be extended to neurosurgeons, particularly those with limited surgical experience, to narrow the gap between knowledge and its practical application concerning 3D-printed guide plates for intracerebral haemorrhage procedures.

The findings of this study offer significant insights into the knowledge, attitudes, and practices (KAP) of neurosurgeons regarding the use of 3D-printed guide plates in puncture and drainage surgeries for intracerebral haemorrhage. A key observation is the presence of substantial knowledge and positive attitudes, contrasted with the inactive practice among neurosurgeons in this area. This gap between knowledge/attitude and practice represents a critical discussion point, especially in the realm of clinical application and the adoption of technology in neurosurgery. The factors of age and experience, which are indicative of higher knowledge and practice scores among neurosurgeons aged over 45 and those with more than 15 years of experience, support the idea that clinical expertise accumulates over time20. Nonetheless, this raises questions regarding the assimilation of novel technologies such as 3D printing among younger, less experienced surgeons. The impact of professional title and hospital grade on attitudes and practices, notably in Tertiary grade B hospitals, may reflect the variability in resource allocation and institutional endorsement for innovative methods21,22. One possible explanation for this finding is that senior neurosurgeons, owing to their extensive clinical and surgical experience, may more readily appreciate the potential advantages of improved precision and safety offered by 3D-printed guide plates. In addition, senior neurosurgeons are more likely to practice in tertiary hospitals where access to innovative technologies and collaborations with biomedical engineers are more common. Their involvement in teaching and mentoring junior colleagues may also encourage a more proactive attitude toward adopting and promoting new surgical methods. This implies that institutional factors significantly influence the adoption of new technologies in surgical practices. Notably, the marked association between participation in training for 3D-printed guide plate-guided puncture and drainage surgery and higher KAP scores underscores the critical role of specialised training in embracing new medical technologies. This finding resonates with literature emphasising the importance of continuous professional development in the enhancement of medical skills and knowledge23.

The multivariable logistic regression analysis further clarifies the independent predictors of practice. The absence of training in 3D-printed guide plate-guided puncture and drainage surgery was identified as a notable negative predictor, highlighting the essential need for targeted training programmes. The positive correlation between the number of surgical cases and practice underscores the ‘learning by doing’ aspect of surgical expertise, consistent with experiential learning theory24,25. Correlation analyses that reveal positive relationships between knowledge, attitude, and practice support the KAP theory, suggesting that knowledge impacts attitudes, which in turn influence practices26. The Structural Equation Modelling (SEM) analysis elaborates on this by demonstrating both direct and indirect influences of knowledge on practice, mediated through attitudes. This is congruent with the theory of planned behaviour, proposing that attitudes mediate the relationship between knowledge and practice27.

The knowledge dimension of this study underscores that neurosurgeons possess a robust familiarity with designing safe puncture pathways whilst avoiding critical intracranial structures, highlighting a strong commitment to procedural safety. However, the aspect least familiar to them pertains to the printing duration and post-processing of the guide plates. To mitigate these identified knowledge gaps concerning the utilisation of 3D-printed guide plates, it is crucial to bolster training programmes for neurosurgeons. The incorporation of comprehensive modules on 3D printing technology within the existing training curricula will ensure neurosurgeons are well-versed not only in the procedural applications but also in the technical complexities involved in the printing process. Proposed strategies could encompass workshops and seminars dedicated to the intricacies of 3D modelling, printing materials, and post-processing techniques. Moreover, promoting collaborations with biomedical engineers and 3D printing experts could afford neurosurgeons practical insights and hands-on experience, effectively narrowing the divide between theoretical knowledge and technological adeptness28,29.

Regarding attitudes, there was a pronounced consensus on the potential of 3D-printed guide plates to increase puncture precision, reflecting a favourable view of 3D printing technology in enhancing surgical accuracy. Conversely, perspectives on the cost and accessibility of 3D printing technology were more divided, with 27.4% strongly concurring that 3D printing apparatus is costly. This apprehension aligns with wider healthcare technology trends, wherein cost and accessibility constitute significant impediments, as elucidated in earlier studies15,30. Given the diverse attitudes towards the expense and accessibility of 3D-printed guide plates, the implementation of strategies to ameliorate these concerns is imperative. Healthcare institutions might conduct cost-benefit analyses to underscore the long-term benefits of employing 3D printing in neurosurgical procedures, thereby rationalising the initial expenditure. This measure could facilitate the acquisition of financial support or subsidies from healthcare authorities or technology grants. Additionally, educational initiatives aimed at elucidating the cost-effectiveness and clinical advantages of 3D-printed guide plates are vital31,32.

The practice dimension highlights a significant engagement gap: whilst 24.2% of participants consistently adhere to knowledge and research reports concerning 3D-printed guide plates, a mere 14.8% are able to flawlessly execute their use in procedures. This discrepancy underscores a translational gap between the acquisition of knowledge and its practical application, mirroring challenges observed in the integration of novel technologies within healthcare settings33. To mitigate this gap between knowledge acquisition and practical application in the deployment of 3D-printed guide plates, the initiation of practical workshops and hands-on training sessions is advocated. Such sessions ought to be structured to immerse neurosurgeons in real-life scenarios, thereby facilitating the practice of applying 3D-printed guide plates within simulated environments10,34. Moreover, the establishment of mentorship and peer learning initiatives within neurosurgical departments could enable the sharing of practical knowledge and experiences. These programmes are instrumental in fostering a culture of continuous learning and the dissemination of best practices, both of which are crucial for the effective integration of new technologies into clinical practices. This strategy not only augments skill enhancement but also cultivates a collaborative milieu that is favourable to innovation and the adoption of technology35,36.

Our findings call for the development of standardized, hands-on training workshops organized by national neurosurgical societies. These should emphasize not only theoretical understanding but also practical competencies such as 3D modeling software operation and the application of guide plates in simulated surgical environments. Beyond training, hospital administrators and policy makers should consider providing financial support, optimizing reimbursement policies, and facilitating broader access to 3D-printing resources. Such multi-level strategies could narrow the gap between knowledge and practice and accelerate the safe and effective clinical translation of this technology.

This investigation acknowledges several limitations that merit consideration when interpreting its outcomes. Primarily, the reliance on self-reported data from neurosurgeons may introduce self-report bias, heightening the risk of socially desirable responses or inaccuracies. Another important limitation concerns the self-reported nature of the knowledge component. As knowledge was assessed by questionnaire responses, there is an inherent risk that participants could claim knowledge without truly possessing it. To mitigate this, we explicitly provided an “uncertain” response option in the knowledge section and emphasized to participants that they could choose this option if unsure, in order to avoid random guessing. Nonetheless, the possibility of overestimation of knowledge cannot be fully excluded. Secondly, the cross-sectional design utilised curtails the capacity to ascertain causality or observe temporal shifts in the behaviours of neurosurgeons, indicating the necessity for longitudinal or interventional studies to gain a more rounded comprehension. Lastly, the study’s concentration on neurosurgeons from a specific region or healthcare setting could limit the applicability of its findings to a wider array of healthcare professionals or disparate healthcare scenarios, necessitating caution in the extrapolation of these results more broadly.

Conclusion

In sum, neurosurgeons demonstrated adequate knowledge and positive attitudes but exhibited inactive practices regarding the use of 3D-printed guide plates in directing puncture and drainage surgeries for intracerebral haemorrhage. To narrow the existing divide between knowledge and practice in the application of 3D-printed guide plates for these surgeries, bespoke training programmes and ongoing education are imperative for neurosurgeons. Furthermore, the promotion of practical experiences through surgical cases and the heightened awareness of this technology’s advantages may culminate in enhanced clinical outcomes.