Imaging in COVID 19

1. Case presentation

2. • 51 years gentleman known case of RT PCR
• HRCT scan was performed.

7. Imaging in COVID 19

8. • Coronavirus disease 2019 (COVID-19) emerged at
the end of 2019,resulting in a global pandemic.
• As of April 27, 2021, 148,470,711 confirmed
cases and 3,133321 confirmed deaths have been
reported in the world.
• In Nepal 303561 confirmed cases and 3176
deaths till today

9. • COVID-19 is caused by a single-stranded
RNA virus named severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2)
• COVID-19 primarily targets the lung, with patients
presenting with pneumonia that can result in acute
respiratory distress syndrome (ARDS).
• COVID-19 can result in multiorgan systemic disease,
affecting the brain, gastrointestinal system, heart,and
kidneys, either directly or indirectly through the host’s
inflammatory response and a hypercoagulable state

10. Imaging
• Chest radiography, CT, and point-of-care lung US have
important roles in the care of patients with COVID-19.
• A diagnosis of COVID-19 is confirmed by reverse
transcriptase–polymerase chain reaction (RT-PCR).
• In patients with a positive RT-PCR test result
with moderate or severe clinical features of COVID-19,
chest imaging can be used to evaluate the baseline
severity of any lung disease

11. • Reporting systems have been
published that summarize the typical imaging
findings and categorize those findings
according to the level of suspicion
• These systems can be applied to patients
under investigation and to those with
incidentally depicted findings

12. • In a low-prevalence scenario, a higher rate of
false-positive examinations may ensue
• In a high-prevalence scenario, a larger number
of false-negative examinations, meaning more
frequently atypical appearances for COVID-19,
will probably be encountered.
• Chest radiography is shown to be less sensitive
and specific than CT.

13. • Point-of-care lung US performed by health
care providers may aid in monitoring
treatment response during hospitalization.

14. Indications for Imaging in COVID-19
 Imaging can play a role in:
• Triage of patients:
- no COVID-19
- possible or most likely COVID-19
- severity of the disease
• Prediction of worsening
• Prediction of improvement
• Problem solver

15. Chest X ray

16. Chest film of a 83 year old male with mitral insufficiency, pulmonary hypertension and
atrial fibrillation with COVID-19 infection.
Ground-glass opacification and consolidation in right upper lobe and left lower lobe
(arrows).

18. • Findings of COVID-19 on CXR vary, ranging
from normal in the early stages of disease to
unilateral or bilateral lung opacities,
sometimes with a basilar and strikingly
peripheral distribution

19. Radiographic Assessment of Lung Edema
(RALE) score proposed by Warren et al
• A score of 0–4 was assigned to each lung
depending on the extent of involvement by
consolidation or ground-glass opacities:
• 0.no involvement;
• 1.25%;
• 2.25%–50%;
• 3.50%–75%; and
• 4.75% involvement.
The scores for each lung were summed to
produce the final severity score.

20. • consolidation was the most common finding
followed by ground-glass opacities
• Peripheral distribution and
lower zone distribution were the more common
locations, and most had bilateral involvement
• Pleural effusion was found in two patients
Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected
Pneumonia

21. CT Scan
• The role of imaging has evolved during the
pandemic,initially with CT as alternative and
possibly superior test compared to RT-PCR, to
a more limited role based on specific
indications.

22. CT Scan
Triage
• Some published clinical guidelines recommend chest CT for patients
with suspected COVID-19.
• The decision to use of CT for triage depends on many
considerations:
• A prior chance of COVID-19 infection.
CT availability, for instance can one CT be used as Corona- CT or is
there a CT near the emergency room.
• clinical suspicion in patients with negative PCR.

23. The typical chest CT appearance of
COVID-19 pneumonia
• Bilateral peripheral opacities with a
lower lung distribution
• Opacities are usually :
Ground-glass opacity (GGO):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

24. CT-images of a young male, who had fever for ten days with progressive
coughing and shortness of breath.
Saturation at admission was 66%.
The PCR test was positive for COVID-19.
There are widespread bilateral ground-glass opacities with a posterior
predominance.

25. • Additional imaging patterns resembling
organizing pneumonia include a perilobular
pattern of opacification and a “reverse halo”
sign, defined as a focal, rounded area of GGO
surrounded by a ring or arc of denser
consolidation

26. 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

27. Traction
Bronchiectasis
Another
common finding
in the areas of
ground glass is
traction
bronchiectasis
(arrows)

28. Vascular dilatation
A typical finding in
the area of ground
glass is widening of
the vessels (arrow).

29. Subpleural bands and
Architectural
distortion
In some case there is
architectural
distortion with the
formation of
subpleural bands.

30. • CT involvement score

31. https://www.ajronline.org/doi/pdf/10.2214/AJR.20.23034

32. CT changes over time

33. Advanced-phase disease is associated
with a significantly increased frequency of:
• GGO plus a reticular pattern (crazy paving)
• Vacuolar sign
• Fibrotic streaks
• Air bronchogram
• Bronchus distortion
• Subpleural line or a subpleural transparent line
• Pleural effusion

35. CO-RADS
• The standardized assessment of pulmonary
involvement of COVID-19 on unenhanced chest
CT images and to report its initial interobserver
agreement and performance.
• A categorical CT assessment scheme for suspicion
of pulmonary involvement of coronavirus disease
2019 (COVID-19) provides a basis for gathering
scientific evidence and improved communication
with referring physicians

36. • The Dutch Radiological Society developed CO-RADS
based on other efforts for standardization, such as the
Lung Imaging Reporting and Data System or Breast
Imaging Reporting and Data System.
• CO-RADS assesses the suspicion for pulmonary
involvement of COVID-19 on a scale from 1 (very low)
to 5 (very high). The system is meant to be used in
patients with moderate to severe symptoms of COVID-
19.

40. Reference
• Imaging Profile of the COVID-19 Infection: Radiologic Findings and
Literature Review
• COVID-19 Imaging: What We Know Now and What Remains Unknown
• Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–
Infected Pneumonia
• Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging
Findings in 919 Patients
• Rapidly progressive ARDS secondary to COVID-19 infection - Eurorad case
16660
• CT Features of Coronavirus Disease 2019 (COVID-19) Pneumonia in 62
Patients in Wuhan, China
• Chest CT in COVID-19: What the Radiologist Needs to Know
• COVID-19 Imaging: What We Know Now and What Remains Unknown
• CO-RADS: A Categorical CT Assessment Scheme for Patients
Suspected of Having COVID-19—Definition and Evaluation

41. Thank you!!!