Background: Acute Stroke Prognosis Early CT Scores (ASPECTS) for MCA (original ASPECTS) and PCA (PC-ASPECTS) are staples of modern stroke management. For treatment decision-making in large ischemic core patients (e.g. endovascular thrombectomy and hemicraniectomy), measures of ACA and total hemisphere ischemia are also desirable. Methods: We developed ratings for anterior cerebral artery territory (AC-ASPECTS) and total supratentorial hemisphere (H-ASPECTS). The ACA was assigned 3 subregions: A1 - inferior; A2 - anterosuperior; and A3 - posterosuperior (Figure). The 16-point H-ASPECTS score is the sum of the MCA (10 regions), supratentorial PC (2 regions), AC-ASPECTS (3 regions) and anterior choroidal territory (1 region). We rated initial and 24h CT/MR images in patients with ischemic stroke due to ICA, M1 MCA, or ACA occlusions. Results: Among 50 consecutive patients, age was 74.7 (±13.9), 60% female, NIHSS 15 (9-20). Occlusion locations were: ICA 36%; M1-MCA 56%; ACA 8%. Treatments included EVT+/- thrombolysis in 72%, IV thrombolysis only in 8%, and hemicraniectomy in 4%. Time from last known well to 1st imaging was 393m (114-851) and 2nd imaging 32h (29-41). ACA abnormality was present in 18% of patients, among whom median AC-ASPECTS were: initial scan median 3 (IQR 3-3); 24h 3 (0-0). On 1st imaging, 8% had A1, 4% A2, and 6% A3 involvement; on 2nd imaging 8.6% had A1, 13% A2, and 13% A3. By occlusion site, H-ASPECTS was: ICA 9 (6-12); M1 MCA 12 (11-13); ACA 15 (12-17). AChA abnormality was present in 2%. Correlation between initial NIHSS and initial imaging score was higher for H-ASPECTS than standard ASPECTS, r = 0.47 vs 0.20. Conclusions: AC-ASPECTS and H-ASPECTS expand the scope of AIS imaging scores and increase correlation with presenting deficits. This additional information may improve decision-making in patients with large ischemic cores, including for endovascular thrombectomy and hemicraniectomy. Figure AC-ASPECTS Regions