REVIEW ARTICLE www.ijcmr.
com Section: Radiology
Suspected COVID 19 Patients in Emergency Department: HRCT
Chest and CO-RADS Classification System, A Pictorial Review
Puneet Raj Goyal1, Amandeep Goyal2
ABSTRACT
Coronavirus Disease 2019 (COVID-19) pandemic has rapidly
resulted in global health emergency. Because of limitations
of RT-PCR assay and other rapid detection tests, chest CT
can aid in early diagnosis and management of patients with
suspected COVID-19 presenting in emergency department.
This pictorial review provides radiologists with an overview
of various High Resolution CT scan chest manifestations of
COVID 19 and also the CO-RADS reporting system which can
help in making accurate diagnosis and better communication
to referring physician.
Keywords: COVID-19, CO-RADS, HRCT Chest
INTRODUCTION
With the increasing prevalence of coronavirus disease-19
(COVID-19) worldwide, timely detection of COVID-19
infection in patients presenting to emergency department
with SARI and distinguishing them from other causes
has become crucial to ensure rapid prevention and early
treatment.1
As of now, methods for detection of COVID-19 such as
real-time reverse-transcriptase polymerase chain reaction
(RT-PCR) tests or rapid antigens tests are either not readily
available, or have high relative false negative rate or require
several hours for the result.2
Performing chest CT for detecting COVID-19 related
pulmonary lesions may be a helpful test for patients suspected
of COVID-19 infection at the beginning of admission in the
emergency department.3
With almost similar time taken to obtain nasal swab and
HRCT, the turn around time of result of HRCT is instantaneous
as compared to 4-5 hours for RT-PCR at present.4 Therefore,
radiologist needs to be familiar with the imaging findings of
COVID-19 to make accurate diagnosis, clinical suggestions
and help in limiting the spread of disease.1
CO-RADS, (COVID-19 Reporting and Data System), is
non enhanced chest CT scan based assessment scheme for
pulmonary involvement in patients suspected of COVID-19
and has very good predictive value for COVID-19 patients.5
CO-RADS categorical system assesses the suspicion of lung
involvement, providing standardized communication to
clinicians for better and early decision making. However to
build a clinical diagnosis of COVID-19 before availability
of RT-PCR test results, it has to be interpreted together
with clinical and laboratory findings.5 Also Final diagnosis
however relies on RT-PCR positivity for the presence of
coronavirus.2
Through this pictorial review, we aim to illustrate the various
International Journal of Contemporary Medical Research Section: Radiology
ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 10 | October 2020
HRCT CHEST manifestations of suspected COVID-19
patients who present to the emergency department and
categorize them according to CO-RADS.
Various CT manifestations of COVID-19 are shown in
a pictorial fashion to help radiologists familiarize these
possible imaging features.
Ground glass opacity, Fig 1
The earliest and most common CT manifestation of COVID
19 is unifocal or multifocal, unilateral or bilateral, Ground
glass opacities (GGOs) with predominant peripheral and
subpleural distribution. GGOs together with small areas of
consolidation may suggest an organizing pneumonia pattern
of lung injury.6
Crazy paving pattern, Fig 2
Crazy paving pattern of thickened interlobular septa and
intralobular lines superimposed on a GGOs background,
resembling irregular paving stones is another common
finding of COVID-19.7
Consolidation, Fig 3
Multifocal, patchy, or segmental consolidation, with
subpleural or peribronchovascular distribution, is usually
present in COVID-19 patients and is an indicator of disease
progression.8
Reticular pattern, Fig 4, Fig 5
Reticular pattern seen as coarse linear opacities or fine
sub-pleural reticulation due to thickened interlobular and
intralobular septa is relatively late but common chest CT
manifestation of COVID-19.9
Subpleural curvilinear line, Fig 6
It manifests as a thin curvilinear opacity with 1–3 mm
thickness, lying less than 1 cm from and parallel to the
pleural surface.8
Air bronchogram, Fig 7
Air bronchogram seen as air-filled bronchi on a
1
Consultant Radiologist, Department of Radiodiagnosis, Amar
Hospital, Patiala, Punjab, 2Consultant Radiologist, Department of
Radiodiagnosis, Max Superspeciality Hospital, Saket, New Delhi,
India
Corresponding author: Dr. Puneet Raj Goyal, Consultant
Radiologist, Department of Radiodiagnosis, Amar Hospital,
Patiala, Punjab, India
How to cite this article: Goyal PR, Goyal A. Suspected COVID
19 patients in emergency department: HRCT chest and CO-RADS
classification system, a pictorial review. International Journal of
Contemporary Medical Research 2020;7(10):J1-J5.
DOI: http://dx.doi.org/10.21276/ijcmr.2020.7.10.16
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Goyal, et al. COVID 19 Patients in Emergency Department: HRCT Chest and CO-RADS Classification System

background of high attenuation airless lung is another CT

manifestation of COVID-19. Moreover, this can often be
accompanied by slight bronchiolar dilatation termed as
bronchiolectasis.7
Bronchial Wall Thickening and Bronchiectasis, Fig 8
Bronchial wall thickening and bronchiectasis are seen less
commonly in COVID-19 pneumonia and are more frequent
in later stages and in critical patients.10
Vascular Dilation or Thickening, Fig 7 Figure-1: HRCT scan Axial and coronal images of same patient
Vascular enlargement often occurs as the dilatation of small show multiple predominantly peripheral patchy ground-glass
pulmonary vessels around and within lung parenchymal opacities with bilateral distribution.
lesion like ground glass opacity or consolidation.11
Pleural changes, Fig 9
Pleural thickening is more prevalent than pleural effusion.
Presence of pleural effusion can be due to underlying co-
morbid condition or may suggest a poor prognosis in
COVID-19.10
Halo sign, Fig 10
Halo sign, though an uncommon finding in COVID-19, is
seen as a nodule or mass surrounded by ground glass haze.6
Figure-2 a and 2b: HRCT scan of two different patients shows
Reversed Halo Sign, Fig 10 extensive areas of reticulations superimposed on the background of
The reversed halo or atoll sign is seen as a central focal area GGOs resembling crazy paving pattern.
of ground glass opacity surrounded more or less complete
ring-like consolidation.12
Fibrosis, Fig 11, 12
Fibrous lesions may form during the healing of chronic
pulmonary inflammation. CT manifestations of fibrosis in
COVID-19 suggest disease stabilization. However, some
reports argue that fibrosis may progress to pulmonary
interstitial fibrosing disease.13
Lymphadenopathy
Mediastinal and hilar lymphadenopathy is very uncommon
Figure-3: Predominantly peripheral areas of consolidation in both
finding and is considered as risk factor of severe pneumonia
lower lobes along with GGOs and crazy paving pattern.
or bacterial superinfection.10,14 Based on the CT findings, the
level of suspicion of COVID-19 infection is graded from
very low or CO-RADS 1 to very high or CO-RADS 5 and
the severity and stage of the disease is determined.
An overview of CO-RADS is given in Table 1 and a pictorial
overview is presented in subsequent section.5
CO-RADS 1
CO-RADS 1 signifies very low level of suspicion for
pulmonary involvement and COVID-19 is highly unlikely,
eg. normal CT scan or CT findings of non-infectious
etiology like emphysema, congestive heart failure (Fig 13 a), Figure-4a and 4b: HRCT scan images of two different patients
interstitial lung disease, lung tumors etc. show subpleural areas of reticular pattern in basal regions of both
lower lobes.

CO-RADS Category Level of Suspicion HRCT features

1 Very low Normal or non infectious cause
2 Low Consistent with Infections other than COVID-19
3 Indeterminate Overlapping features seen in COVID-19 as well as other diseases
4 High Abnormalities Suspicious for COVID-19
5 Very high Typical COVID-19 abnormalities
6 RT-PCR Positive
Table-1: CO-RADS Categories and the Level of Suspicion of COVID-19 infection

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Section: Radiology International Journal of Contemporary Medical Research
Volume 7 | Issue 10 | October 2020 | ISSN (Online): 2393-915X; (Print): 2454-7379
Goyal, et al. COVID19 Patients in Emergency Department: HRCT Chest and CO-RADS Classification System
Figure-5a and 5b: HRCT scan images of two different patients
shows subpleural curvilinear lines (arrows).
Figure-6: HRCT scan shows bilateral GGOs and thick linear
fibrous stripes in both lower lobes.
Figure-7: HRCT scan images of same patient at two different levels
show small vascular enlargement and air bronchograms within
patches of GGOs in right upper (fig a) and right lower lobes (fig b).
Figure-8: HRCT scan image shows area of GGO, consolidation
with air bronchogram, bronchial wall thickening and bronchiectatic
changes in right middle lobe (black frame)
Figure-9: HRCT scan shows left pleural thickening (arrow).
International Journal of Contemporary Medical Research Section: Radiology
ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 10 | October 2020
Figure-10: HRCT scan shows small nodules surrounded by a
ground glass halo in both upper lobes (Halo sign, fig a). HRCT scan
shows a reversed halo sign in subpleural region of right lower lobe
(arrow in fig b).
Figure-11: HRCT scan shows extensive predominantly peripheral
areas of fibrosis, consolidation with pleural thickening and mild
traction bronchiectasis suggesting relatively late phase of disease.
Figure-12: HRCT scan image of patient recovered from COVID
19 shows residual extensive fibrotic changes with interstitial
thickening and architectural distortion in both lungs.
Figure-13: CO-RADS 1, interstitial pulmonary edema with pleural
effusion (fig a). CO-RADS 2, Lobar consolidation along with
centrilobular nodules and tree-in-bud pattern (fig b).
CO-RADS 2
CO-RADS 2 signifies low level of suspicion of COVID-19
infection in which CT findings are typical of other infectious
etiology like bronchopneumonia, lobar pneumonia,
pulmonary abscess. Features include centrilobular nodules,
tree-in-bud appearance, lobar or segmental consolidation
(Fig 13 b) and cavitation.
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Goyal, et al. COVID 19 Patients in Emergency Department: HRCT Chest and CO-RADS Classification System

CO-RADS 3
CO-RADS 3 signifies equivocal findings and COVID-19
infection is indeterminate based on CT features alone,
that can also be found in other etiologies like widespread
bronchopneumonia, perihilar or homogenous extensive
ground glass opacities (Fig 14 a, b) with or without pleural
effusion. Single unilateral ground glass opacity is also
considered in this category (Fig 15).
CO-RADS 4
CO-RADS 4 signifies a high level of suspicion for COVID-19 Figure-17: CO-RADS 4, Axial HRCT image shows ground glass
infection. CT findings are typical for COVID-19 but may and reticulations superimposed on severe centrilobular emphysema
in COVID-19 RT-PCR positive patient.
not be located in contact with the visceral pleura, may be
strictly unilateral (Fig 16) or superimposed on pre-existing
pulmonary abnormalities (Fig 17) or showing some overlap
with other (viral) pneumonias.
CO-RADS 5
CO-RADS 5 signifies a very high level of suspicion for

Figure-14: CO-RADS 3, Axial HRCT images of 53 year old

male with history of cardiovascular and chronic renal disease,
who presented with fever and cough since 3 days (fig a). He had a
negative RT-PCR test for SARS-CoV-2 and a repeat CT scan after
dialysis (fig b) shows complete resolution of ground glass opacities
suggesting pulmonary edema to be likely cause.
Figure-18: CO-RADS 5 in COVID-19 positive patients, (a)
Multifocal bilateral subpleural areas of ground-glass opacities,
(b) Extensive areas of bilateral ground-glass opacities with
inter and intralobular septal thickening (“crazy paving”) and
early consolidation. Relatively late phase disease (c) organizing
pneumonia like pattern and (d) extensive fibrotic changes in both
lungs.

COVID-19 infection. Obligatory features include ground-

Figure-15: CO-RADS 3, Axial HRCT images shows aingle
unilateral focus of ground-glass opacity in right lower lobe in a
COVID-19 RT-PCR positive patient.
Figure-16: CO-RADS 4, axial (fig a) and coronal (fig b) images
show unilateral multifocal ground-glass opacities with crazy paving
pattern, early consolidation and pleural contact in a COVID-19
positive patient.
glass opacities, with or without consolidations, close to
visceral pleural surfaces, multifocal and bilateral distribution.
In Early phase of disease dominant pattern is multiple
ground-glass areas (Fig 18a). With disease progression
these areas evolve into crazy paving pattern and increasing
consolidations appear (Fig 18 b). Eventually organizing
pneumonia like pattern (Fig 18 c) and fibrosis (Fig 18 d)
occurs. Subpleural curvilinear bands and thickened vessels
within lung abnormalities are associated frequent and typical
findings.
CO-RADS 6
CO-RADS 6, indicates RT-PCR proven COVID-19.
CONCLUSION
In conclusion, with surge in COVID-19 pandemic cases and
many patients presenting to emergency department with
acute respiratory symptoms, HRCT scan of chest is a rapid
and reliable tool to triage patients suspected of infected with
COVID-19. Familiarity with imaging findings of COVID 19
and further communicating the results to referring physician
through structured and fast reporting system like CO-RADS,

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Section: Radiology International Journal of Contemporary Medical Research
Volume 7 | Issue 10 | October 2020 | ISSN (Online): 2393-915X; (Print): 2454-7379
Goyal, et al. COVID19 Patients in Emergency Department: HRCT Chest and CO-RADS Classification System

as presented in this review article, radiologist can play a https://doi.org/10.1148/radiol.

crucial role in management of this global outbreak.
Ethical Approval: Source of Support: Nil; Conflict of Interest: None
As this is retrospective and observational/ pictorial review Submitted: 01-09-2020; Accepted: 01-10-2020; Published: 31-10-2020
of the patients for whom chest CT scan was indicated to
diagnose the infection, ethical approval is not required.
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ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 10 | October 2020