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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.

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.

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.

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.