Background: Prognostication has evolved with tools like the Glasgow Coma Scale (GCS) and neuroimaging, yet predictors of clinical progression and surgical necessity remain debated. This study aimed to identify factors predicting clinical/radiological progression, surgical intervention, and functional outcomes in isolated traumatic brain contusions. Methods: A prospective study of 100 patients (50 conservative [Group A], 50 surgical [Group B]) with isolated contusions. Serial CT scans, neurological assessments (GCS, Glasgow Outcome Scale [GOS]), and clinical monitoring were performed. Surgical intervention was guided by clinical deterioration (e.g., GCS decline) and radiological progression (midline shift ≥5 mm). Results: Group A (Conservative): Mild GCS (13–15) correlated with favorable 3-month GOS (4.9 ± 0.3) and shorter hospital stays (4.6 ± 2.0 days), while severe GCS (3–8) predicted poor outcomes (GOS 1.5 ± 0.7, 20% mortality). Midline shift negatively correlated with GOS (ρ=-0.53, P=0.01) and prolonged hospitalization (ρ=0.57, P=0.007). Radiological progression occurred in 16% (8/50), but only 4 required surgery due to clinical decline. Group B (Surgical): Severe GCS (3–8) linked to longest stays (17.5 ± 3.8 days) and highest mortality (25%). Midline shift worsened postsurgery (3.96 ± 1.62 mm to 6.40 ± 1.35 mm), correlating with poorer GOS (ρ=-0.52, P=0.01). Polytrauma patients (84%) had worse outcomes (GOS 3.2 ± 1.8 vs. 4.5 ± 0.6 in localized trauma). Conclusions: Midline shift and initial GCS are pivotal in guiding management. Conservative care suffices for mild cases, while surgery mitigates risks in severe injuries, albeit with residual mortality. Keywords: Traumatic Brain Contusion; Glasgow Coma Scale; Midline shift; Surgical Intervention; Conservative management