Moderate isolated contusion selected for early surgery — STITCH numbers, TXA, drains and VTE timing

Case

Station: You are the on-call surgeon. Argue the plan aloud with trial numbers at each step; the examiner interrupts with complications.^[16]

Decide surgery: Isolated 28 mL contusion, moderate injury (GCS 10), within the STITCH gate (up to two bleeds of at least 10 mL, within 48 h) — early evacuation within 12 h won favourability 63 vs 53% with deaths 15 vs 33%, and CENTER-TBI confirms the win sits exactly here (moderate isolated: adjusted ORs 1.5-1.8).^[16][17] A mild small bleed would watch; this one operates.^[17]

Give TXA now: 6 hours exceeds the 3-hour CRASH-3 fence — state openly that the mortality benefit (mild-moderate RR 0.78, optimal within 2 h) no longer applies, and do not pretend otherwise.^[18][19]

Control pressure: Place the drain early — beyond-24-h placement more than doubles bad odds (aOR 2.14) — and run osmotherapy for episodes knowing neither agent changes outcome.^[27]

Cover and counsel: Phenytoin load within 24 h for 7 days (week-1 seizures 3.6 vs 14.2%, then stop); VTE drugs within 72 h of surgery on a stable scan (5 vs 13% clots, no extra re-bleed); counsel moderate-injury contusion as the best surgical bet in head trauma, not a guarantee.^[29][38][17]