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Introduction Thrombolytic therapy is standard in acute ischemic stroke, but intracranial neoplasms pose high hemorrhagic risk. This case illustrates direct mechanical thrombectomy in a patient with stroke, a large frontal meningioma, vasogenic edema, carotid dissection, and bilateral pulmonary emboli.Abstract C94 Figure 1Case Description A 59-year-old hypertensive female presented with headache, dyspnea, and sudden aphasia. Initial NIHSS was 2, escalating to 22 in the ED. CT showed a 3.3 cm anterior frontal meningioma with vasogenic edema. CT angiography revealed tapered occlusion of the left carotid artery and non-opacification of the left ICA. CT-PE protocol confirmed bilateral central pulmonary emboli. Given the meningioma and cerebral edema, thrombolysis was contraindicated. Emergent thrombectomy targeted the left M1 and CCA, achieving TICI 2b/3 reperfusion. Despite persistent ICA occlusion, ACA and MCA were patent post-procedure. Neurological status stabilized. Due to bilateral PEs, anticoagulation was initiated with heparin and transitioned to cangrelor.Abstract C94 Figure 2Conclusions This case highlights two key insights:Mechanical thrombectomy without thrombolytics was critical. The large meningioma and edema contraindicated IV tPA due to hemorrhagic risk. Successful revascularization demonstrates thrombectomy’s value as a primary therapy in complex neuro-oncologic stroke.Risk-balancing in dual pathology: Although thrombolytics could have benefited the pulmonary emboli, intracranial bleeding risk precluded their use. In patients with concurrent neurovascular and cardiopulmonary threats, therapeutic choices must prioritize safety while preserving efficacy.Abstract C94 Figure 3Conflict of Interest No