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I play Twitch in an unorthodox way, but have had a lot of success and felt I'd share with the community. The majority of the times that I select twitch in ranked matches, there is instant QQ in regards to how horrible Twitch is. The bottom line however, isn't that Twitch is bad, its that a lot of people playing him do so very poorly.
Twitch was not nerfed in my opinion a few patches back. The increase to his attack speed is huge while his damage is still top notch. It has required changes to the way he is played to be effect, however.
More times than not, dominate the mid regardless of the opponent, and am able to effectively carry the team in kills as well as push towers and backdoor.
Pros / Cons
High attack speed
Very good damage
High powered Ultimate
Oracles / Wards can be problematic
Positioning is very important
I go with Alacrity Marks, Seals, and Glyphs, with Fortitude Quints.
As mentioned in the introduction, attack speed is Twitches best friend. With the runes and masteries suggested, attack speed is up over .8 attacks per second at level 1 without any items boosting it. By mid game, coming out of stealth for the bonus attack speed, you can easily be capped at 2.5 attacks per second.
The Fortitude Quints are a no brainer, Twitch is squishy with a lower natural health. This gives him a little beef for the early to mid game.
I opt for the boots of speed and 3 health pots for survivability, increased potential to gank other lanes, and staying power with the health regen. I replenish my health pots everytime I buy, until I run out of item slots.
Early - Mid Game
My first item is always Mandreds Bloodrazor. With Twitches attack speed the 4% damage per attack is huge, every second it does 10% above and beyond the actual damage you do when you are capped on your attack speed. It also adds some good attack damage and armor.
I tend to mix it up as to when I finish off my boots based on how I feel in the game. Sometimes I get the Boots of Mobility after I pick up the runecurve bow for Mandreds Bloodrazor, other times I wait until Mandreds Bloodrazor is finished if the money is just rolling in. Boots of Mobility allow Twitch to get to ganks and teamfights faster. Getting there faster, especially while stealthed leads to more kills for you and your team.
Infinities edge always comes after the boots and Bloodrazors. Lots of attack damage, a lot of crit, and the extra damage per crit. With all the attacks you have flying out at 2.5 per second, crits happen frequently, maximizing the extra damage.
I tend to opt for Frozen Mallet as my fourth item. It gives a huge boost to health, a little damage, and compounds your ability to slow targets. Enemies have a tough time getting away, can easily be kited, and can be kept from chasing down your allies. Mix in Debilitating Poison and they are going no where fast, even with ghost.
At this point I play it by ear based on the other team and what I feel is needed. Lately I find myself picking up Banshee's Veil or The Bloodthirster as my 5th item. If they're heavy AP and tend to be doing good damage, I'll take Banshees, if I haven't been to threatened I go for Bloodthirster.
For the last item its again dependent on the other team and my needs. It could be Banshees, Bloodthirster, Black Cleaver, etc.
If you complete your item build, dont forget to buy elixits and oracles. Oracles even if they dont have a stealther / Teemo will reveal their wards for you to take out.
I go with Heal (or noob heal as enemies like to call it when they're dead as a result of it), and Smite. With this combination I'm consistantly able to pull first blood and gain several more kills through mid game that I wouldn't usually be able to get and may even die without the heal.
Smite obviously is to add extra damage, but its also very good against enemies like Mundo when he pops his ultimate to devastate the healing ability they're relying on. Its much more effective for pure damage at lower levels.
In Ranked Matches you can expect to see a lot more Vision Wards and Oracles. THESE DO NOT COMPLETELY SHUT DOWN TWITCH. They simply make it so you can't stealth without being seen. You can still farm mobs, you can still attack enemies, you just dont have the luxury of surprise. If you're the stronger champion at whatever point in the game, stealth is just icing on the cake. You do not have to be unseen to be able to light and enemy up or push a lane. It helps and is nice, but far from necessity.
Positioning / When to Pop Out
9 times out of 10 you want to position yourself closer to your team than the enemies, if not completely behind your team to minimize the enemies opportunity to focus you.
Sometimes, however (especially in ganks where its small numbers like 2v2 or 1v1), its a great idea to sneak to the far side of the enemy, between where they are and where they want to go. This allows you to open up on them, build some stacks and slow them, keeping them in range without having to move or risk them getting out of range.
I take mid whenever possible. I tend to own any other champion 1v1 early game with expunge, ignite, and heal. ALWAYS KNOW YOUR OPPONENTS SUMMONER ABILITIES! If they have ignite, it can ruin your day when you're relying on heal.
I tend to do a couple hit and runs, getting a hit or two on them and then expunging as they fall back, and using a health pot to recover and damage they or their minions do to me (make sure you're down at least 200 hp before you pop a pot though, no sense in wasting it). They also tend to prematurely pop ignite with this method if they have it, removing the concern for it when I go for the kill.
If they dont run away and ignite is not an issue, I stay in and blast them as much as possible, popping a pot on first damage and heal between 25 and 50% health. Save Expunge for when they are at two bars of health, with 5 or 6 stacks its usually a guaranteed kill.
I also constantly check the side lanes for gank opportunities. If you've done a few hit and runs by dropping back out of sight, stealthing, and then going in for a few hits, they will assume this is the case and fail to call mias. Any enemey champ below half health is an easy gank.
If someone is adamant about taking mid or I'm playing with a friend and end up in the side lane, I take stealth before expunge and follow the same system.
I also will take stealth first if they have an enemy jungler that I can expect to start at the golem buff. I speed down to the single bush in the river and hide out until 1:55 when the golem spawns. Stealth in the bush and head over, he should be low enough by the time you get there to gank him and steal the buff. If he's got guards and you're alone, just walk away unless you're confident you can get the kill on him and make it out. Its not worth it for you to die.
Mid and late game its about playing with your team and positioning yourself to be able to lay the smack down without exposing yourself and being an obvious target. If they head your way, fall back and let your team have some fun with them and resume your attacks when they stop pursuing you. The key is not being out alone unless you're supremely confident that they will not have vision wards and oracles. A Twitch alone vs multiple enemies, is a dead Twitch (unless you're ungodly fed or they're terribad).
There are lots of pieces of terrain you can shoot through and force the enemy to have to walk around to get to you. You can also steal barren, dragon, lizard buffs, and golem buff this way.