Case presentation

● COVID-19 is a viral disease also known as SARS-CoV-2 or severe acute

respiratory syndrome coronavirus 2.
● The diagnosis is made by a positive PCR test, which is highly specific.
● CT has a higher sensitivity but lower specificity and can play a role in the
diagnosis and treatment of the disease.
Clinical features
● COVID-19 usually presents with fever (85%), cough (70%) and shortness of
breath (43%), but abdominal and other symptoms are possible and the
disease can be asymptomatic.
● Illness severity can vary from mild to critical.
1. Mild: no symptoms, mild caughing and fever.
2. Severe: dyspnea, hypoxia or > 50% lung involvement on imaging.
3. Critical: respiratory failure, shock, multi-organ failure.
 Imaging
Ground glass

● Ground glass (GGO) pattern is the most common finding in COVID-19

infections.
● They are usually multifocal, bilateral and peripheral, but in the early phase of
the disease the GGO may present as a unifocal lesion, most commonly
located in the inferior lobe of the right lung
There are widespread
bilateral ground-glass
opacities with a posterior
predominance.
Crazy paving
● Sometimes there are thickened interlobular and intralobular lines in
combination with a ground glass pattern.
● This is called crazy paving.
● It is believed that this pattern is seen in a somewhat later stage.
Vascular dilation
A typical finding in the area of ground glass is widening of the vessels
Traction Bronchiectasis
Another common finding in the areas of ground glass is traction bronchiectasis
Subpleural bands and Architectural distortion
In some case there is architectural distortion with the formation of subpleural
bands
CT involvement score
Method is by scoring the percentages of each of the five lobes that is involved:

< 5% involvement

5%-25% involvement

26%-49% involvement

50%-75% involvement

> 75% involvement.

The total CT score is the sum of the individual lobar scores and can range from 0
(no involvement) to 25 (maximum involvement), when all the five lobes show more
than 75% involvement.
Initial CT-findings
Initial CT-findings in COVID-19 cases include bilateral, multilobar ground glass
opacification (GGO) with a peripheral or posterior distribution, mainly in the lower
lobes and less frequently in the middle lobe .

Consolidation superimposed on GGO as the initial imaging presentation is found

in a smaller number of cases, mainly in the elderly population.

Septal thickening, bronchiectasis, pleural thickening, and subpleural involvement

are some of the less common findings, mainly in the later stages of the disease.

Pleural effusion, pericardial effusion, lymphadenopathy, cavitation and

pneumothorax are some of the uncommon but possible findings seen with disease
progression.
CO-RADS classification
CORADS 1

● COVID-19 is highly unlikely.

● The CT is normal or there are findings that indicate a non-infectious disease
like congestive heart failure, sarcoid, histoplasmosis, malignancy, UIP or
fibrotic NSIP.
● An exeption has to be made for the first few days of a mild infection when the
CT can be normal.
CORADS 2
● Level of suspicion of COVID-19 infection is low.
● Findings consistent with other infections like typical bronchiolitis with
tree-in-bud and thickened bronchus walls.
● No typical signs of COVID-19.
● The CT-image shows bronchiectasis, bronchial wall thickening and
tree-in-bud.
● There are no ground glass opacities.
Bronchiectasis, bronchial wall
thickening and tree-in-bud.
Bronchial wall thickening,
tree-in-bud and consolidation.
Lobar consolidation and tree-in-bud
consistant with a bacterial infection,
i.e. CORADS 2.

COVID-19 unlikely.
CORADS 3
COVID-19 unsure or indeterminate.

CT abnormalities indicating infection, but unsure whether COVID-19 is involved,

like widespread bronchopneumonia, lobar pneumonia, septic emboli with ground
glass opacities.
Unifocal ground glass opacity
Multifocal consolidations with
surrounding GGO.
Bilateral central consolidations with diffuse GGO.
CORADS 4
● In CO-RADS 4 the level of suspicion is high.
● Mostly these are suspicious CT findings but not extremely typical:
● Unilateral ground glass
● Multifocal consolidations without any other typical finding
Unilateral areas of
GGO in left upper lobe

Bilateral GGO in a
patient with
emphysema.
CORADS 5
● Very high suspicion of COVID.
● Multifocal GGO and consolidation
●
Multifocal areas of groundglass and
consolidation
CORADS 6
● Patient with positive PCR and bilateral GGO.
●
Ground glass opacity
● Ground-glass opacity is a nonspecific term that refers to the presence of a
hazy increase in lung opacity and is not associated with obscuration of
underlying vessels or bronchial margins.
● If vessels are obscured, the term consolidation is used.
GGO doesn’t obscure the
underlying vessels.
● Ground-glass opacity results from the volume averaging of morphologic
abnormalities, too small to be clearly resolved by HRCT.
● It can reflect the presence of minimal thickening of the “septal” or alveolar
interstitium; thickening of alveolar walls; interstitial inflammation, infiltration, or
fibrosis; or the presence of cells or fluid partially filling the alveolar spaces.
Significance of Ground-Glass Opacity
● Ground-glass opacity is a highly significant finding because it often indicates
the presence of an ongoing, active, and potentially treatable process.
● In patients with acute symptoms, the association of ground-glass opacity with
active disease is very high.
● For example, in patients with AIDS and acute respiratory distress,
ground-glass opacity visible on HRCT accurately predicts the presence of
Pneumocystis jirovecii pneumonia.
● In patients who have subacute or chronic symptoms, ground-glass opacity
also suggests the likelihood of active disease, although in this setting, lung
fibrosis can also result in this finding.
Acute onset GGO
Subacute/chronic onset GGO
● The most common causes of ground-glass opacity in patients having
subacute or chronic symptoms include interstitial pneumonias such as
nonspecific in pneumonia (NSIP).
Ground-glass opacity
predominates in the posterior
and the peripheral lung, there
is subpleural sparing, and
finding that suggests NSIP.
DIP in a 39-year-old smoker.
Ground-glass opacity
predominates in the peripheral
lung, with some subpleural
sparing. Cysts are visible within
the areas of ground-glass opacity.
Patchy ground-glass opacity associated with hypersensitivity pneumonitis.
Upper-lobe predominance noted.
Crazy-Paving Pattern
● Ground -glass opacity with superimposition of a reticular pattern results in an
appearance termed crazy paving.
● In patients with crazy paving, ground-glass opacity may reflect the presence
of airspace or interstitial abnormalities;
● The reticular opacities may represent interlobular septal thickening, thickening
of the intralobular interstitium, irregular areas of fibrosis, or a preponderance
of an air space filling process at the periphery of lobules or acini
Ground-glass opacity
and crazy paving in a
patient with pulmonary
hemorrhage.

Vessels are visible

within the area of
opacity, as are
thickened interlobular
septa.
Pitfalls in diagnosis of GGO
● Ground -glass opacity reflects the volume averaging of subtle morphologic
abnormalities , the thicker the collimation used for scanning, the more likely
volume averaging will occur, regardless of the nature of the anatomical
abnormality present. Thus, ground-glass opacity should be diagnosed only on
scans obtained with thin collimation.
● Increased lung opacity is commonly seen in the dependent lung, largely as a
result of volume loss in the dependent lung parenchyma ; this is called
dependent density . This can result in a stripe of ground-glass opacity several
centimetres thick in the posterior lung of supine patients; prone scans allow this
transient finding to be distinguished from a true abnormality.
● Expiration, because of a reduction of the amount of air within alveoli, lung
regions increase in attenuation and can mimic the appearance of ground-glass
opacity resulting from lung disease
 Mosaic perfusion
● Lung density and attenuation are partially determined by the volume of blood
present within pulmonary vessels.
● Thus, regional differences in lung perfusion in patients with airways disease
or pulmonary vascular disease can result in inhomogeneous lung opacity.
● When Mosaic perfusion is present, pulmonary vessels in the areas of
decreased opacity usually appear smaller than vessels in relatively dense
areas of lung.
● This discrepancy reflects differences in regional blood flow and can be quite
helpful in distinguishing mosaic perfusion from patchy ground-glass opacity
(GGO), which can have a similar appearance.
Vessels appear larger in relatively dense
lung regions, a finding of great value in
making the diagnosis of mosaic perfusion.

The relatively dense lung regions are

normally perfused or overperfused
because of shunting of blood away from
the abnormal areas.

Abnormal airways (i.e., bronchiectasis,

bronchial wall thickening) are visible in
relatively lucent lung regions.
 Patchy areas of mosaic perfusion are
visible, with decreased vascular size within
the lucent regions.
Differention between GGO and mosaic perfusion
● The most important HRCT finding in determining the presence of mosaic
perfusion is reduced vessel size in lucent lung regions. If reduced vessel size
is visible in lucent regions, a confident diagnosis of mosaic perfusion can
usually be made.
● In patients with vascular obstruction (e.g., CPTE) as a cause of mosaic
perfusion, dilatation of central pulmonary arteries may be present as a result
of pulmonary hypertension and larger areas of low attenuation are usually
visible.
● Ground-glass opacity may be accurately diagnosed as the cause of
inhomogeneous lung opacity if it is associated with other findings of infiltrative
disease such as consolidation , reticular opacities.
MIXED DISEASE AND THE
HEADCHEESE SIGN
● Combination of ground-glass opacity (or consolidation) and reduced lung
attenuation as a result of mosaic perfusion. This combination of mixed
attenuation, including the presence of mosaic perfusion, often gives the lung a
geographic appearance and has been termed the headcheese sign.
● The headcheese sign is often indicative of mixed infiltrative and obstructive
disease.
● The most common causes of this pattern are hypersensitivity pneumonitis
sarcoidosis, atypical (viral or mycoplasma) infections with associated
bronchiolitis,desquamative interstitial pneumonia (DIP) or respiratory
bronchiolitis-interstitial lung disease (RB-ILD) associated
Inhomogeneous lung attenuation consisting of ground-glass opacity and
multiple lobular areas of lucency due to mosaic perfusion .Small or invisible
vessels in lucent regions.
● Expiratory HRCT scans may be useful in the diagnosis of mosaic attenuation
and can usually allow the differentiation of mosaic perfusion resulting from
airways obstruction from other abnormalities when the inspiratory scans are
inconclusive.
● In patients with ground-glass opacity, expiratory typically shows a proportional
increase in attenuation in areas of both increased and decreased opacity.
● In patients with mosaic perfusion resulting from airways disease, attenuation
differences are accentuated on expiration ,relatively dense areas increase in
attenuation, whereas lower-attenuation regions remain lucent (i.e., air trapping
is present).
● Mosaic perfusion resulting from vascular disease, expiratory findings often
mimic those seen in patients with ground-glass opacity; both low-attenuation
and high-attenuation regions increase in attenuation on expiration
Proportional increase in lung
attenuation in both dense and lucent
lung regions.