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For conquest hunters blessing, any other mode I prefer attackers for the added pen.
Attacker's Blessing
Boots
Healing Potion
Mana Potion
Hunter's Blessing
Ninja Tabi
The Crusher
Qin's Sais
Bloodforge
Brawler's Beat Stick
Titan's Bane
Y
B
A
X
This is a revised version of my first ever guide. Originally I had some flaws in the guide but now after tweaking things I find that the core items are huge for Medusa. Currently I have over 2800 worshipers, over 1800 kills, and over 1100 assists with Medusa. With only a handful of games with the pen build I’ve gotten two godlikes.
Either warrior or ninja tabi can come to personal preference. I will use either or depending upon the build I’m using or team I’m playing against.
The Crusher is a huge bonus off of the poison damage from Medusa’s 1, it grants additional tick damage, with attack speed and pen you can’t go wrong.
Qins Sais adds additional attack speed and damage allowing you to chunk enemies.
Bloodforge/asi lifesteal is entirely up to you. But if I’m going to pick ninja tabi I’m likely to get bloodforge. If I’m getting warrior tabi im likely to get asi. Give and take with the attack speed. Both have great passives, but ultimately up for your judgement.
The last couple items for each build are where there is some wiggle room. In the pen build brawlers is good anti heal, and executioner is great % pen. Wind demon has a nice passive and death ringer gives great burst damage. These last two are able to be more situational.
1 viper shot: 3/4 shots with increased attack speed and tick damage. Great for boxing or initiating. Before leaving fountain it can be beneficial to use the ability to save mana early game. Level this second.
2 acid spray: a line shot that cones out after hitting an enemy. This is your wave clear and can be great to manipulate to hit enemy gods. This is your highest damaging ability as well as your greatest poke potential. Level this first.
3 lacerate: your dash, if it hits an enemy god they receive reduced healing as well as being rooted. Great for chasing enemies or escaping to safety. A great combo with this is to ult, then basic one or two times and then dash into them hindering any mobility.
4 petrify: the bread and butter of Medusa. Great for initiating fights, securing fights, saving team mates, and protecting yourself if you are tower dived. This ability does great damage and turns the enemy gods to stone. If you kill a god while turned to stone they will remain there until destroyed as a statue.
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Crit as your first item isn't really ever a good choice. Even if you buy it after boots there are only a few exeptions.
For conquest you should try stacking
She doesn't suffer any penalty moving sideways
Just my opinion
- Crit efficiency usually requires at least 35-40% for it to be an effective force. Getting
Deathbringer before ANY other full item means you're relying exTREMELY heavily on a very low % chance...sure, getting that last hit (as a crit) as you say on a 1/4 health enemy is "nice," but it's going to be very rare. If they're at 1/4 health, they shouldn't be anywhere near you, so either you're playing against low skill players, or you've got some really nice teammates that are able to distract and CC like crazy to hold the enemy down while you crawwwwl up to them slowly (or use your 
Lacerate and burn your only escape...).
- DB first is enormously expensive. Sure, since you don't get anything else you're only waiting for 1,700 gold, which isn't the longest...but...
- It also wants attack speed to have more opportunity to actually do something. And if you're doing the "I'm gonna go all out early" thing...
Qin's Sais is actually going to get you significantly more DPS than even a completed DB as a first item, AND it's cheaper. Just using that as an example...I wouldn't get Qin's first...but still.
If you're facing a mirror match with aUsing http://eliteownage.com/smitebuilder.html for calculations.
3,300 gold gets you
Now we'll make some general assumptions...using level 5 for the calculations...mirror
At 0 stacks of
Now, if you box, and we start seeing
Basically...you rely on RNG, you don't get any move speed so can get killed more easily, and you're going to lose out on DPS if they just get
Now, for your Arena build, you'll probably want to replace
Finally, for Conquest, of course I understand it's not updated because
At least seeing
As it is, it's just not a good build to recommend for a new player, and an experienced player will likely outplay these builds with a normal one.
I never said these builds were perfect, they're just how I happen to build her. I have over 70 hours played with medusa, over 2000 worshippers, a 56% win/loss ratio, and a 1.6k/d and 2.2k/d/a ratios. I've always had great success with these builds, I even went 32-5 in conquest with that build and had no issues in doing so.
After trial and error these are what I have come up with, and with the skill I have with her I am able to pull these off. But this all comes down to opinions and play styles.