RADIOLOGY IMAGING OF COVID-19

Dr Bekti Safarini, SpRad ( K)TR

Faculty of Medicine, Sultan Agung Islamic University
Radiology Installation of Sultan Agung Islamic Hospital Semarang
 BACKGROUN
• D
COVID-19: an infectious disease caused by a coronavirus
species (SARS-CoV-2)novel coronavirus (2019-nCoV).
• The first case in Wuhan, China in December 2019 
spread throughout the world  pandemic in March
2020.
• Radiology imaging  help diagnose can assess the
severity of the disease and its progression.
 CLINICAL FEATURES
• 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

Mild: no symptoms, mild caughing and fever.

Severe: dyspnea, hypoxia or > 50% lung involvement on
imaging.

Critical: respiratory failure, shock, multi-organ failure.
 LABORATORY FINDING

• Leukopenia
• Lymphopenia
• Thrombocytopenia
• Increased CRP
 RT-PCR TEST
• Very specific, but has a lower sensitivity of
60-70%  the test can be negative even
when the patient is infected.
• The results of test can take more than 24
hours, while CT results are available
right away
 Radiology decision tool for suspected COVID-
19 Bilateral (peripheral) Definite/ Probable
Isolate
opacification** COVID-19 pattern**

CT SCAN***
Seriously ill Uncertain/ Normal Indeterminate
CXR (Pre-contrast ± CTPA)
Sats <94%* or NEWS>=3

Clinical assessment and Clinico-radiological

labs Non-COVID-19 disease Don't isolate review
Suspected COVID-19
< 50% have fever but >
80% have lymphopenia
Self isolate with follow
Abnormal CXR ? COVID-19
up
Stable CXR
Sats > 94%. NEWS <3 If clinically required
Normal CXR home with advice Self Isolate

If neither COVID-19 less

likely

*94% unless known COPD in which case <90%

** Unsuspected/ unexpected cases may be incidentally discovered on CXR/ CT at this stage; should be reviewed in the context of clinical suspicion as to likelihood of COVID-19.
***Classic and Indeterminate CTs should be scored either: ‘mild’ or ‘moderate/severe’

Please upload all COVID 19 cases to BSTI database: https://www.bsti.org.uk/training-and-education/covid-19-bsti-imaging-database/

 CHEST X RAY ( CXR )
• CXR performed in isolation room with mobile xray
• CXR is less sensitive than CT
• 50% the first case in Singapore has a normal CXR
• Subpleural GGO/ Consolidations
• Usually multifocal & bilateral, can also unilateral.
• Pleural effusions is reraly
According to RSNA CXR reporting for COVID-19 for both adults and
children is divided into 4 categories, as follows:
• Typical  bilateral peripheral and / or subpleural ground glass
opacity and / or consolidation
• Indeterminate  less specific than typical finding findings such as
unilateral non-segmental or lobar ground glass opacity /
consolidation or multifocal ground glass opacity / consolidation
without specific distribution
• Atypical  unilateral segmental or lobar consolidation that is
more like bacterial pneumonia, its distribution is central, can be
round consolidation without and with air bronchogram. In this
finding we mention an alternative diagnosis
• Negative  pneumonia (-)
 After 9 days from
the first CXR

After 4 days
Male, 50 years old
Fever, cough
Lymphopenia
High level CRP
COVID-19 (+)
Male, 60 years old
Fever, dyspnea
Leukopenia
Lymphopenia
High level CRP
COVID-19 (+)
Male, 40 years old.
Fever, cough, dyspnea,
Diarrhoea.
Lymphopenia
High level CRP
COVID-19 (+)
Male, 49 years old
Fever, Cough
Trombocytopenia
Lymphopenia
COVID-19 (+)
 CHEST CT SCAN
Chest CT scan can be performed on :
• Patients especially with comorbid clinically suspected pneumonia and
no evidence was found on CXR
• Patients with high suspicion of COVID-19, but negative RT-PCR results (-)
• Critical patients who require emergency procedures, who cannot wait for the
results of RT-PCR, chest radiographic results are inconclusive, and CT-scan facilities
are available.
• The radiology instalation must have capable of carrying out maintenance
procedures and decontamination of radiological equipment and space, and is
able to carry out optimal protection for health workers and non-COVID-19 visit
populations.
CHEST CT SCAN

https://radiologyassistant.nl/chest
 Ground glass
opacity (GGO )
• The most common finding in
COVID-19 infections.
They are usually multifocal,
bilateral and peripheral.
• 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.
https://radiologyassistant.nl/chest
 CHEST CT SCAN
Advanced-phase disease is associated with a
significantly increased frequency of:
• GGO plus a reticular pattern (crazy paving)
• Vacular sign
• Fibrotic streaks
• Air bronchogram
• Bronchus distortion
• Subpleural line or a subpleural
transparent line
• Pleural effusion
 Crazy Paving
• Thickened interlobular &
intralobular lines in
combination with a ground
glass pattern.
• This pattern is seen in a
somewhat later stage.

https://radiologyassistant.nl/chest
Traction Bronchiectasis
Another common finding in the areas of ground glass is traction
bronchiectasis (arrows).

https://radiologyassistant.nl/c
Subpleural bands and Architectural
distortion
In some case there is architectural distortion with the formation of
subpleural bands.
https://radiologyassistant.nl/c
https://radiologyassistant.nl/chest
 This 59 year old
female had a history of
ten days of fever &
five days of coughing.
The O2 saturation:89
RR : 30/min.
There are widespread
GGO's without
consolidation. No
architectural
distortion.
This was
reported as
early phase
COVID-19.

https://radiologyassistant.nl/chest
  Fever 1 week
 Abdominal pain
 Diarrhoea.
 a dry cough.
 Dizziness.
 The O2-saturation
was low.
 The PCR-test was
not known

https://radiologyassistant.nl/chest
• Bilateral subpleural GGO’s.
• Consolidation in right lower lobe with traction bronchiectasis (green
arrow).
• Fibrous bands (yellow arrow).
Based on the CT-findings COVID-19 infection was assumed to be highly likely
 late phase
The chest film is insensitive early in the disease.
Here a comparison of a chest radiograph and CT image.
The ground glass opacities in the right lower lobe on the CT (red arrows)
are not visible on the chest radiograph, which was taken 1 hour prior to the
CT-study
Ming-Yen NG et.al, 2020
TABLE 1. Proposed Reporting Language for CT Findings Related to COVID-19, Including Rationale, CT Findings and Suggested
Reporting Language for each Category
COVID-19
Pneumonia Imaging
Classification Rationale6–11 CT Findings* Suggested Reporting Language
Routine Screening CT for Diagnosis or Exclusion of COVID-19 is Currently not Recommended by Most Professional Organizations or the US Centers for
Disease Control and Prevention
Typical Commonly reported imaging Peripheral, bilateral, GGO with or “Commonly reported imaging features of
appearance features of greater without consolidation or visible (COVID-19) pneumonia are present. Other
specificity for COVID- intralobular lines (“crazy-paving”) processes such as influenza pneumonia and
19 pneumonia organizing pneumonia, as can be seen with drug
toxicity and connective tissue disease, can cause a
similar imaging pattern.” [Cov19Typ]†

Multifocal GGO of rounded morph- ology

with or without consolidation or visible
intralobular lines
(“crazy-paving”)
Reverse halo sign or other findings
of organizing pneumonia (seen later in the
disease)
Indeterminate Nonspecific imaging features Absence of typical features and “Imaging features can be seen with (COVID-
appearance of COVID-19 presence of: 19) pneumonia, though are nonspecific and
pneumonia Multifocal, diffuse, perihilar, or unilateral can occur with a variety of infectious and GGO with or
without consolidation noninfectious processes.” [Cov19Ind]† lacking a specific distribution
and are
non-rounded or non-peripheral
Few very small GGO with a non-rounded
and non-peripheral distribution
Atypical Uncommonly or not Absence of typical or indeterminate “Imaging features are atypical or
appearance reported features of features and presence of: uncommonly reported for (COVID-19)
COVID-19 pneumonia Isolated lobar or segmental pneumonia. Alternative diagnoses should be
consolidation without GGO considered.” [Cov19Aty]†
Discrete small nodules
(centrilobular,
“ tree-in-bud” )
Lung cavitation
Smooth
with pleural effusion
Negative for No features of Nointerlobular
CT featuresseptal
to suggest pneumonia. No CT findings present to indicate
pneumonia pneumonia thickening pneumonia. (Note: CT may be
negative in the early stages of
COVID-19.) [Cov19Neg]†
* Please see35 for specific definitions of CT findings.
† Suggested coding for future data mining.
Suggested reporting language includes coding of CT findings for data mining. Associated CT findings for each category are based upon available literature at the time of writing in
March 2020, noting the retrospective nature of many reports, including biases related to patient selection in cohort studies, examination timing, and other potential confounders.
Notes: 1. Inclusion in a report of items noted in parenthesis in the Suggested Reporting Language column may depend upon clinical suspicion, local prevalence, patient status as a PUI,
and local procedures regarding reporting; 2. CT is not a substitute for RT-PCR, consider testing according to local recommendations and procedures for and availability of RT-PCR.
GGO indicates ground glass opacity.

Simpson S et.al, 2020

 CT patterns
Pattern Description
CLASSIC COVID-19 Lower lobe predominant, peripheral predominant, multiple, bilateral* foci
(100% confidence for of GGO
COVID) ±
• Crazy-paving
• Peripheral consolidation**
• Air bronchograms
• Reverse halo/ perilobular pattern**

PROBABLE COVID-19 • Lower lobe predominant mix of bronchocentric and peripheral

(71-99% confidence for consolidation
COVID) • Reverse halo/ perilobular pattern**
• GGO scarce

INDETERMINATE • Does not fit into definite, probable or Non-Covid

(<70% confidence for • Manifests above patterns, but the clinical context is wrong, or
COVID) suggests an alternative diagnosis (e.g. an interstitial lung disease in a
connective tissue disease setting)
NON-COVID • Lobar pneumonia
(70% confidence for • Cavitating infections
alternative) • Tree-in bud/ centrilobular nodularity
• Lymphadenopathy, effusions
• Established pulmonary fibrosis
*>1 lesion, but could still be unilateral; usually but not universally bilateral1
**i.e. organising pneumonia patterns
 CT pattern and quantifying disease

Radiology Parenchymal lung changes Severity

Classic/Probable/Indeterminate Up to 3 focal abnormalities 3cm in max

Mild
diameter

More than 3 focal abnormalities or max

Moderate / Severe*
diameter >3cm

* The difference between moderate and severe is subjective and will likely differ between reporters.
This should be used in conjunction with clinical assessment.
 CT pattern and quantifying disease (2)

Radiology in probable COVID-19 Severity

Up to 3 focal abnormalities < 3cm in

Pure ground glass opacities Mild
max diameter

Pure ground glass opacities More than 3 focal abnormalities or max Moderate /
diameter >3cm Severe*

Focal ground glass opacities Moderate /

mixed with early consolidation Severe*

Diffuse ground glass opacities

or consolidation with signs of
architectural distortion Severe

* The difference between moderate and severe is subjective and will likely differ between reporters.
This should be used in conjunction with clinical assessment.
Cong-Ying Song et al, 2020
Covid-19: BSTI/BSGAR decision tool for chest
imaging in patients undergoing CT for acute surgical
abdomen Acute Surgical Abdomen
Clinical decision already made that
• Urgent CT abdomen / pelvis is required
• Patient is stable enough to be sent to CT

Assess Covid-19 Probability*

Take swab for PCR if not already done
Low Probability* High Probability*
• Neutrophilia • Lymphopenia (<1.0)
• Apyrexial • No other likely cause (NB
• Alternative diagnosis more coronavirus can cause
likely abdominal symptoms)
• CXR (if already done) normal or • CXR (if already done) showing
showing alternative diagnosis** classic or probable COVID-19**
Do not do CXR just to look for COVID if the patient needs a CT A/P anyway

CT ON NON-COVID SCANNER CT ON COVID SCANNER

• CT Abdomen/Pelvis (typically PV phase) • CT Abdomen/Pelvis (typically PV phase)
• Plus EITHER low dose non-con CT chest OR • Plus EITHER low dose non-con CT chest OR
all post-contrast (i.e. CT CAP) all post-contrast (i.e. CT CAP)

RAPID CT REVIEW

Non-COVID/indeterminate COVID classic/probable

• Cannot exclude COVID
• However, combination of
• Consider the patient COVID-
negative CT and low
positive
probability could aid surgical
• Correlate with swab when
decision to operate or treat
result available
conservatively
• If at all possible, wait for • Clean CT scanner as per COVID
swab protocol
results as well
*Probability assessment as per PHE & local guidance

**In some cases the patient may have already had a CXR, and this could
help guide COVID probability assessment as per the BSTI/NHSE radiology
decision tool. See https://www.bsti.org.uk/covid-19-resources/ . If no CXR
has been performed, as per NELA guidance we would suggest going straight
to CT.

BSTI/BSGAR_chestCTinAcuteAbdomen_v1_25.03.2020
 REKOMENDASI PDSRI
• Penggunaan pemeriksaan radiologi untuk tujuan skrining tidak disarankan
• Ruangan pemeriksaan yang digunakan untuk Pasien COVID-19
sebaiknya terpisah dari ruang radiologi induk.
• Radiografi toraks merupakan pemeriksaan radiologi utama dalam
diagnosis COVID-19
• CT-scan toraks memiliki peran dalam deteksi dini dan evaluasi penyakit COVID-
19, sehingga dapat membantu manajemen klinis, dengan tetap memperhatikan
kewaspadaan dan keselamatan alat, lingkungan dan pekerja radiasi.
• Pada keadaan klinis dan laboratorium yang sesuai dengan COVID-19 dijumpai
gambaran typical COVID-19 pada CT scan toraks walaupun test RT-PCR negatif,
maka harus dilakukan pemeriksaan ulang RT-PCR.
• Hasil CT-scan toraks yang normal, belum menyingkirkan diagnosis infeksi COVID-
19
• USG paru sangat tidak direkomendasikan untuk melihat pneumonia Covid-19.
• Perlu memperhatikan dan menjalankan prosedur pemeriksaan yang aman dan
melakukan prosedur desinfeksi pada ruang radiologi secara rutin.
 CONCLUSION
• Typical finding by chest radiograph in frist coming patient  chest
CT no need
• Atypical finding chest radiograph with RT-PCR (+) could be done
Chest CT if possible
• The imaging features of COVID-19 pneumonia are highly
nonspecific and are more often bilateral with subpleural and
peripheral distribution and range from ground-glass opacities in
milder forms to consolidations in more severe forms
• Chest CT scan has a role in the early detection & evaluation of
COVID-19 disease, so that it can help clinical management, while
paying attention to the safety of the equipment, the environment
& radiation workers.
 REFERENCES
• BSTI. 2020. Radiology decision tool for suspected COVID-19.https://www.bsti.org.uk/training-and-education/covid-19-bsti-
imaging-database/
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https://www.bsti.org.uk.
• BSTI/BSGAR_chestCTinAcuteAbdomen_v1_25.03.2020
• Cong-Ying Song et al, COVID-19 early warning score: a multi-parameter screening tool to identify highly suspected patients.
medRxiv preprint doi: https://doi.org/10.1101/2020.03.05.20031906.
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Pedoman Pencegahan dan Pengendalian Coronavirus Disease (COVID-19)
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