Thrombus imaging features influencing the choice of first-line thrombectomy strategy: an international survey of neurointerventionists.

INTRODUCTION: Endovascular thrombectomy (EVT) is the standard of care for large vessel occlusion stroke, but the optimal first-line strategy remains debated. Thrombus imaging features may help guide device selection, yet their impact on neurointerventionists' decision-making is unclear. METHODS: We conducted an international anonymous survey distributed through JENI and ESMINT networks (January-April 2025). The questionnaire collected demographic data, imaging availability, and responses to 12 case vignettes illustrating thrombus characteristics. Physicians selected their preferred first-line EVT strategy among six options. Subgroup analyses were performed according to physician's procedural volume. RESULTS: A total of 161 stroke physicians from 35 countries responded (median age 40 years; 58% senior attendings). Both CT and MRI were available in 83% of institutions, but CT was more frequently used for screening. Across 1911 responses, combined stent-retriever plus aspiration (44.6%) and contact aspiration (39.2%) were most often selected. Respondents favored the combined strategy (>70%) for long thrombi, and contact aspiration (>66%) for short thrombi. In bifurcated occlusions, the combined technique was preferred by 47.1% of the respondents. Physicians' annual procedural volume was not significantly associated with the choice of first-line EVT strategy. Over half of respondents considered current imaging insufficient to guide EVT choice, and 88% expressed willingness to use artificial intelligence-based decision support tools. CONCLUSIONS: First-line EVT practices remain heterogeneous worldwide, with thrombus length showing a consistent influence on device selection Interest in AI-based tools underscores the need for translational research integrating advanced imaging biomarkers to optimize EVT decision-making.