1Various CT Scan Score in Pneumonia and Covid-19

The Society of Thoracic Radiology, the American College of Radiology, and the
Radiological Society of North America offered additional guidance for the use of both plain
chest radiography and CT imaging for patients suspected to have COVID-19. In consonance with
these guidelines, we do not recommend chest CT imaging for routine diagnostic purposes or as a
screening method in asymptomatic individuals. Chest CT imaging may be useful in moderate to
severe disease in patients who demonstrate worsening gas exchange or show lack of
improvement in respiratory status with time. This may apply to patients with negative RT-PCR
results, but with a high index of clinical suspicion for COVID-19.

1. Scoring based on RSNA (Radiological Society of North America)

COVID-19 lung disease may present with both typical and atypical CT scan findings.
The Radiological Society of North America (RSNA) has provided guidance to
standardize CT scan reporting in patients with COVID19 pneumonia. The RSNA
proposed four categories for reporting CT scan findings: typical, indeterminate, atypical,
and negative

Table 1. Scoring based on RSNA

COVID-19 Rationale CT Scan Findings

Pneumonia Imaging
Classification

Typical Appearance Commonly reported  Peripheral, bilateral, GGO with or

imaging features of without consolidation or visible
greater specificity for intralobular line (crazy paving
COVID-19 pattern)
pneumonia  Multifocal GGO of rounded
morphologic features with or without
consolidation or visible intralobular
line (crazy paving pattern)
 Reverse halo sign or other findings of
organizing pneumonia

Indeterminate Nonspecific imaging Absence of typical features and presence

appearance features of COVID19 of:
pneumonia  Multifocal, diffuse, perihilar, or
unilateral GGO with or without
consolidation lacking a specific
distribution and that are nonrounded
and nonperipheral
 Few small GGO with a nonrounded
and nonperipheral distribution
Atypical appearance Uncommonly or not Absence of typical or indeterminate
reported features of features and presence of:
COVID-19  Isolated lobar or segmental
pneumonia consolidation without GGO
 Discrete small nodules (centrilobular,
“tree-in-bud” appearance)
 Lung cavitation
 Smooth interlobular septal thickening
with pleural effusion

Negative findings for No features of No CT scan features to suggest pneumonia

pneumonia pneumonia

Figure 1.Typical Appearance CT Scan

 Figure 2. Typical Appearance CT Scan

Figure 3. Atypical Appearance Ct Scan

2. Co-RADS Categories
Coronavirus disease 2019 (COVID-19) Reporting and Data System (CO-RADS)
provided a standardized assessment scheme that simplifies reporting with a five-point
scale of suspicion for pulmonary involvement of COVID-19 at chest CT. CO-RADS
provides a level of suspicion for pulmonary in- volvement of COVID-19 based on the
features seen at un- enhanced chest CT. The level of suspicion increases from very low
(CO-RADS category 1) to very high (CO-RADS category 5). Two additional categories
encode a technically insufficient examination (CO-RADS category 0) and RT- PCR–
proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at the
time of examination (CO- RADS category 6).
Table 2. CO-RADS Categories and Level of Suspicion for Pulmonary Involvement in COVID-19
CO RADS Level of Suspicion for Summary
Pulmonary Involvement of
COVID-19
0 Not Interpretable Scan technically insufficient for
assigning a score
1 Very Low Normal or noninfectious
2 Low Typical for other infection but Not
Covid-19
3 Equivocal/unsure Features compatible with Covid-19
but also other diseases
4 High Suspicious for Covid-19
5 Very high Typical for covid-19
6 Proven RT-PCR positive for SARS-Cov-2

 CO-RADS Category 0
CO-RADS category 0 is chosen if none of the five categories can be assigned because scans are
incomplete or of insufficient quality, for example because of severe artifacts due to coughing or
breathing.

 CO-RADS Category 1
highly unlikely, CT is normal, or there are findings indicating a non- infectious disease

 CO-RADS Category 2
the level of suspicion of COVID-19 infection is low, and CT findings are consistent with other
infections. Examples are bronchitis, infectious bronchiolitis, bronchopneumonia, lobar
pneumonia, and pulmonary abscess. Features include tree-in-bud sign, a centrilobular nodular
pattern, lobar or segmental consolidation, and lung cavitation. These features are similar to the
ones in the “atypical appearance” category of the RSNA consensus statement. Cases with smooth
interlobular septal thickening with pleural effusion, which is also part of this RSNA category, are
assigned to CO-RADS category 1 if considered typical for interstitial pulmonary edema or are
assigned to CO-RADS category 3 if ground-glass opacities that may mimic pulmonary
involvement by COVID-19 are also present. This choice was made because CO-RADS describes
the pulmonary, not cardiac, involvement of COVID-19.

 CO-RADS Category 3
COVID-19 infection is unsure or indeterminate, and CT abnormalities indicate infection but are
unsure whether COVID-19 is involved. Findings include perihilar ground-glass opacity,
homogenous extensive ground-glass opacity with or without sparing of some secondary
pulmonary lobules, or ground-glass opacity together with smooth interlobular septal thickening
with or without pleural effusion in the absence of other typical CT findings. CO-RADS category 3
also includes small ground-glass opacities that are not centrilobular (otherwise they would be CO-
RADS category 2) or not located close to the visceral pleura (otherwise they would be CO-RADS
category 4). In addition, it contains patterns of consolidation compatible with organizing
pneumonia without other typical findings of COVID-19. This category partially overlaps with the
indeterminate appearance category of the RSNA consensus statement but includes those cases
with lower likelihood for COVID-19

 CO-RADS Category 4
CO-RADS category 4 implies a high level of suspicion for pulmonary involvement by COVID-19
based on CT findings that are typical for COVID-19 but also show some overlap with other (viral)
pneumonias. Findings are similar to those for CO-RADS category 5; however, they are not in
contact with the visceral pleura, nor are they located strictly unilaterally in a predominant
 peribronchovascular distribution or superim- posed on severe diffuse preexisting pulmonary
abnormalities. CO-RADS category 4 consists of the features of the indeterminate appearance
category of the RSNA consensus statement that are associated with a higher likelihood of COVID-
19.

 CO-RADS Category 5
the level of suspicion is high with typical CT findings. Mandatory features are ground-glass
opacities with or without consolidations in lung regions close to visceral pleural surfaces,
including the fissures, and a multi- focal bilateral distribution. Other classifications only describe a
peripheral location, but we found that the vicinity to the minor or major fissure is also typical.
Subpleural sparing can be present. We found that the previously described lower lobe
predominance is frequently not present in otherwise typical RT-PCR–positive cases; therefore,
lower lobe predominance was excluded as a required feature.

CO-RADS category 5 requires the presence of at least one confirmatory pattern that aligns with
the temporal evolution of the disease. The pattern that has been described early in the course of
COVID-19 is dominated by multiple ground-glass areas, which often show (half) rounded and
unsharp demarcation but can be accompanied by sharply delineated ground-glass areas that outline
the shape of multiple adjacent secondary pulmonary lobules. The crazy paving pattern, which has
been described as appearing later in the course of the disease, shows visible intralobular lines. As
the disease progresses, more consolidations occur within the areas of ground-glass opacity.
Finally, opacities that resemble organizing pneumonia occur, such as reverse halo signs or ground-
glass opacity with extensive subpleural consolida- tions and air bronchograms. Subpleural
curvilinear bands or bands of ground glass with or without consolidation in a tethered arching
pattern with small connections to the pleura are also considered typical findings. Thickened
vessels within lung abnormalities are typical and are frequently found in all other confirmatory
patterns. CO-RADS category 5 is largely identical to the typical appearance of the RSNA
consensus statement

 CO-RADS Category 6
CO-RADS category 6, similar to BI-RADS category 6, was introduced to indicate proven
COVID-19, as signified by positive RT-PCR test results for virus-specific nucleic acid.

3. CT Severity Score (CTSS)

CT severity score (CTSS) is based on a subjective visual assessment of the extent of
disease in each lobe of the lung. Presence of GGO, crazy paving, or consolidation in each
lobe is used for scoring. When present, related features such as fibrosis, subpleural lines,
reversed “halo sign,” pleural effusion, and lymphade- nopathy were also described. Each
lobe has a minimum score of 0 and a maximum score of 5. The total CTSS is the sum of
the individual lobar scores and can range from 0 (no involvement) to 25 (maximum
involvement). A CTSS of 10 and 15 have a specificity of 90% for hospital admission
and ICU admission, respectively. A CTSS of  3 was found to be 90% sensitive for
patient discharge from the ED.A CTSS of 17 is 90% specific for 30-day mortality, and
a score  5 predicts 30-day survival with a sensitivity of  90%.
Table 3. CT Severity Score

CT Severity Score Definition

0 No involvement
1 <5% of lobe involvement
2 5%-25% of lobe involvement
3 26-49% of lobe involvement
4 50-75% of lobe involvement
5 >75% of lobe involvement
4. BSTI Scoring
1. BSTI (British Society of Thoracic Imaging)
 Classic COVID-19 (100% mengarah ke COVID-19)
Hasil CT scan paru dengan gambaran lesi focal GGO di lobus bawah, perifer,
multiple dan bilaterak dengan atau tanpa crazy paving, konsolidasi perifer, air
bronchogram, reverse halo / perilobular pattern
 Probable COVID-19 (71 – 99% mengarah ke COVID-19)
Hasil CT scan paru dengan gambaran dominan di lobus bawah dengan
bronchocentric dan konsolidasi perifer, reverse halo / perilobular pattern
  Indeterminate (< 70% mengarah ke COVID-19)
Hasil CT scan mengarah ke COVID-19 namun klinis mengarah ke penyakit paru
interstitial.
 Non COVID-19
Hasil CT scan memperlihatkan gambaran lobar pneumonia, tree-in bud /
centrilobular nodular, lymphadenopathy, efusi dan fibrosis.2

Bibliography
1. Stephen Machnicki, M. et al., 20211. The Usefulness of Chest CT Imaging in Patients
With Suspected or Diagnosed COVID-19. CHEST, 160(2), pp. 652-670.
2. Thomas C. Kwee, M. R. M. K. M., 2020. Chest CT in COVID-19: What the Radiologist
Needs to Know. RadioGraphics, Volume 40, p. 1848–1865.
3. Suryamin, R., 2021. Modalitas CT-Scan Toraks sebagai Pemeriksaan Penunjang pada
COVID-19. CDK, 48(1), pp. 54-57.
4. MathiasProkop, M., 2020. CO-RADS: A Categorical CT Assessment Scheme for Patients
Suspected of Having COVID-19—Definition and Evaluation. Radiology, Volume 296, pp.
97-104.
5. Hafez, M. A. F., 2020. The mean severity score and its correlation with common
computed tomography chest manifestations in Egyptian patients with COVID-2019
pneumonia. Egyptian Journal of Radiology and Nuclear Medicine, 51(254), pp. 1-9.
6. Simpson, S., 2020. Radiological Society of North America Expert Consensus Statement
on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of
Thoracic Radiology, the American College of Radiology, and RSNA. Thorac Imaging,
35(4), pp. 219-227.
7. Xiao, J., 2020. Maximum chest CT score is associated with progression to severe illness
in patients with COVID-19: a retrospective study from Wuhan, China. BMC Infectious
Disease, 20(953), pp. 1-11.
8. Sayeed, S., 2021. CT Chest Severity Score for COVID 19 Pneumonia: A Quantitative
Imaging Tool for Severity Assessment of Disease. Journal of the College of Physicians
and Surgeons Pakistan, 31(04), pp. 388-392.
9. Kang, M., 2021. Quantitative Assessment of Chest CT Patterns in COVID-19 and Bacterial
Pneumonia Patients: a Deep Learning Perspective. Korean Med Sci, 36(5), pp. 1-14.
10. Francone, M., 2020. Chest CT score in COVID-19 patients: correlation with disease
severity and short-term prognosis. European Radiology, pp. 1-10.