Imaging COVID-19

Aziza Ghanie Icksan

Thoracic Radiologist
RSUP Persahabatan
azizagicksan@yahoo.com
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 Introduction
• Indonesia was declared a COVID 19 pandemic in March 2020
• Imaging has an important role in management pulmonary
diseases ➔ pneumonia
• CXR and CT are key tools , Sonography and Head CT for
complication

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WHO Categories COVID-19
1. Suspected ➔ Febrile , respiratory illness, history travel and local transmission

2. Probable

3. Confirmed

CXR as addition to RT- PCR in suspect, probable and

confirmed case of COVID -19 commonly in Hospital
CT should be used in suspected cases who are RT-PCR
negative or long time waiting for the result ➔ help
3 working diagnosis
 Imaging of COVID 19
• CXR is the most commonly ordered imaging study for patients with respiratory
complaints INCLUDE COVID-19 for screening, working diagnosis, severity
and follow up disease progression ➔ less sensitive compare to Chest CT

• The precise role of imaging remains controversial and varies based on

country and institution.

• The recent COVID-19 radiological literature is primarily focused on CT

findings, which is more sensitive than CXR

Zu ZY et al. Radiology. February 2020:200490.

Zhang H-W, Yu J, Xu H-J, et al.. Acad Radiol. February 2020.
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 CXR HRCT HRCT RT PCR RT PCR
Meta analysis Metanalysis

Sensitivity 69 % 95-97 % 94% 60-70% 89%

Specificity 60-70 % 37% 95-97% 95-97%

HYF Wong et al . Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients. Radiology 2020
Kanne, JP et.al. Essentials for Radiologists on COVID-19: An Update—Radiology Scientific Expert Panel. (2020) Radiology. doi:10.1148/radiol.2020200527
Fatima S, Ratnani I, Husain M, et al. (April 12, 2020) Radiological Findings in Patients with COVID-19. Cureus 12(4): e7651.
Basha MM, Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel. (2020) Radiology

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Chest Radiograph Pattern Of COVID 19

Normal

Typical pattern
Bilateral Opacity , sub segmental consolidation , nodule , interstitial
opacity
Usually peripheral and basal predominant

Atypical pattern
Pleural effusion , nodule

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 Chiara Moroni et al . Chest X-ray in the emergency department during COVID-19 pandemic
descending phase in Italy: correlation with patients' outcome. Radiol Med. 2021
May;126(5):661-668.

Conclusion: In our study, admission CXR

GGO in COVID-19 pneumonia.
Figure a shows an initial interstitial thickening in
both lower pulmonary lobes (arrows).
In figure b ➔ a diffuse basal and bilateral GGO
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showed a fair specificity and a good
correlation with patients' outcome.
GGO and others CXR findings showed a good
correlation with COVID-19 diagnosis;
besides GGO a diffuse or bi basal
distribution resulted in independent
variables highly suggestive for COVID-19
infection thus enabling radiologists to signal
to clinicians radiologically suspect patients
during the pandemic descending phase.
Diffuse lung involvement in COVID-19 pneumonia. Figure a shows a reticular-nodular pattern
in both basal and subpleural parenchyma. Figures in b and c demonstrate diffuse lung
involvement with bilateral consolidations and thickening of peri-broncho vascular interstitium

Radiol Med 2021 May;126(5):661-668.

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Alternative diagnosis. In figure a, an upper-right lobar pneumonia (arrow) with diffuse
inflammatory lung involvement. In figure b, an 82-year-old woman with cardiac failure and
pulmonary edema, hilar congestion (arrow) and cardiomegaly

Radiol Med 2021 May;126(5):661-668.

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 Conclusion:
The presence of patchy and/or confluent,
bandlike ground-glass opacity or consolidation in
a peripheral and mid to lower lung zone
distribution on a chest radiograph obtained in the
setting of pandemic COVID-19 was highly
suggestive of severe acute respiratory syndrome
coronavirus 2 infection and should be used in
conjunction with clinical judgment to make a
diagnosis.

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 Role of chest
radiograph

Indonesia
study
Imaging
CXR
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RSUPP study ➔ Chest radiograph screening participant 418 ➔ 70
Abnormal

Penerbit CV PILAR NUSANTARA SEMARANG

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ISBN: 978-623-7590-74-3
 Ongoing
publish

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The Role of Chest CT
✓ Chest CT is more effective than CXR in the detection of early COVID-19
disease

✓ Some hospitals in China dedicated specific CT scanners for examining

suspected COVID-19 patients only

✓ Typical pattern of Chest CT that can quickly change over a short period of
time and highly suspected COVID-19

Li, X et al . CT imaging changes of corona virus disease 2019(COVID-19): a multi-center study in Southwest China. J Transl Med 18, 154
(2020). https://doi.org/10.1186/s12967-020-02324-w
Expert recommendation from the Chinese Society of Radiology (First edition). Chin J Radiol. 2020
Zu ZY, Jiang M Di, Xu PP, et al. A Perspective from China. Radiology. February 2020:200490. doi:10.1148/radiol.2020200490

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CT SCAN IMAGING FEATURES of COVID-19

50% of patient normal CXR and CT in 0-2days after onset

Lung Abnormalities in early ➔ peripheral focal or multifocal GGO
in both of lungs in 50-75% of cases

As the disease progress ➔ crazy paving pattern. Consolidation

become the dominant CT findings, peak around 9-13 days
followed by slow clearing at approximately 1month

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Step to Read Chest CT in Suspect Pneumonia
COVID 19

✓ Start read from periphery to central

✓ Search pattern abnormality ➔ typical , atypical,
indeterminate, other abnormality
✓ Severity
✓ Timing ➔ depend on characteristic pattern , early,
progressive , peak stage phase and or absorption stage
✓ Compare to previous CT ➔ for follow up

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Chest CT finding in COVID -19

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 Indonesia Chest CT study

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Figure 1 Typical COVID 19 progressive stage, severity BSTI advance .
multiple GGO and mixed GGO and consolidation in both of lower lung lobe ( A.B. red
arrow). Coronal reconstruction CT shows peripheral multifocal GGO (C.D yellow
arrow )and consolidation ( D red arrow) in both of upper n lower lung lobe
Figure 2. Typical COVID 19 progressive stage, advanced stage
Chest CT : Mixed Pattern
Multiple GGO, consolidation and crazy paving

A B C
Figure 3. COVID 19. Transverse CT images shows Reverse hallo sign in right lower
lung lobe ( A.B white arrow )and ground glass opacity in left lower lung lobe ( B. red
arrow)
Four stages of evolution Pneumonia
COVID 19 on Chest CT
1. Early Stage ( 0-4 days )
2. Progressive stage ( 5-8 days)
3. Peak Stage ( 10-13 days)
4. Absorption Stage ( more than 14 days)

Feng Pan et all, Radiology 2020

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CT Manifestations of Different Stages of COVID-19

Wenjing Yang et al. European Society of Radiology 2020

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The imaging Department should dedicate a specific area( including waiting space)
and specific equipment (CT scanner, plain radiography room etc.) to the evaluation
of patients with suspected or confirmed COVID-19, to minimise the risk of
contamination of other patients and concentrate the protective material availability.
Maintenance of radiology services, protection of staff and non-infected members of
the public area for the risk of contamination

Teach Radiologists to recognize the typical radiologic findings that may be

expected in COVID patients in their Report
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 ( IRS / ISTR)suggestion for COVID 19 infection
• CXR usually done in first step imaging
• CXR is less sensitive when compared to CT
• Used for follow up in isolation and ICU ROOM
• Typical finding by CXR in screening ➔ Chest CT no need
• Atypical Finding CXR with RT PCR (+) ➔ Chest CT
• Emergency Case ➔ used CXR if inconclusive and no RT PCR➔
CT if possible

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 COVID -19
RSUPP Cases

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 Case 2 - Screening COVID

Chest Radiograph findings:

Right and left sub pleural upper
and lower and rightparacardial
consolidation multifocal

Conclusion:
Severe Classic pneumonia COVID19

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 Case 3- Screening – F47YOld

Chest radiograph findings:

Right lower peripheral and
paracardial consolidation and left
upper sub pleural GGO

Conclusion:
moderate Classic Pneumonia
COVID 19

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Case 4 A 47YOF suspect COVID with normal Chest Radiograph
➔ Chest CT screening ➔ abnormal Mild Typical Pneumonia
COVID early stage ➔ please Confirm Swab PCR

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Case 5
Clinical finding
cough, Contact (+)
Rapid test I (-) , II
(+) Chest
radiograph Normal
CT Mild typical pneumonia COVID
early stage

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Case 6. 27YOM Contact (+). Clinical finding (-) Chest
radiograph ➔ N ➔ HRCT (+) ➔ PCR still no result

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Case 7. Follow up Chest CT ➔ PCR (-) 42 Days From D/
COVID

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Case 8. 53YOM With COVID 19 , PCR (+) ➔ Follow up CT after
2X PCR (-)

Day 1 Chest
radiograph, PCR (+)
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9. PCR (+), clinical finding fever ➔ chest radiograph Normal

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10. PCR COVID (+) ➔ 2021 and 2022 ➔ normal Chest
Radiograph

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11. Clinical finding Fever , anosmia , PCR (+) , Chest
Radiograph day 1 minimal GGO ➔ 5days ➔ increase
abnormality

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Summary from ITRS/ IRS
Chest Radiograph for COVID 19
1. In community ➔ treatment for isolation asymptomatic /
symptomatic patients

2. Interpretation done by experience doctors with board certified

Radiologist

3. Use portable X ray

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Summary From IRS
Chest CT for COVID 19
1. When Pneumonia suspected clinically and not found by Chest
radiograph

2. High clinical suspicious COVID 19 but RT PCR (-)

3. Critically Ill patient and who will go to emergent operation or

Procedure and can not wait Result of RT PCR and facilities
available
4. Follow up long COVID
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 Key Point
• Imaging has an important role in management starting from screening, working
diagnosis and follow up of infection COVID 19

• Chest radiograph always done in first step imaging and follow up in Isolation and ICU

• Following ACR and RSNA , ESTI, BSTI the Chest CT scan could be used with the right
indications and not for screening of all suspected case

• CT could be used for Follow Up Long COVID to detect Sequel COVID / Fibrosis Lung

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