CT reporting COVID-19

Procedure: Plain Chest CT

History: COVID suspect

Multiple axial tomographic sections of the thorax without IV contrast were obtained.
Ground glass opacities: rounded GGO in bilateral lungs, with some areas demonstrating subpleural
sparing

Margins of consolidation: sharp

Multiple rounded consolidation present

Interlobular & Intralobular septal thickening or crazy paving pattern present/none

Air bronchograms present/ none
Reversed halo present/ none
Predominant distribution: upper lobes/ lower lobes
Predominant AP distribution: ventral/ dorsal/ none
Pleural effusion: none/minimal/ moderate/ massive
lymphadenopathy present/none
pericardial effusion: none/minimal/ moderate/ massive
Other findings: pulmonary emphysema/ fibrosis/ granuloma/ cardiomegaly
Atherosclerosis/ degnerative osseous changes/ others
Others: ___________________________________________

IMPRESSION:Consolidation: unilateral/ bilateral/ peripheral/ central/ none

 Findings of bilateral ground glass densities and multifocal consolidation, predominantly distributed in close
proximity to the visceral pleural regions, consider very high level of suspicion for pulmonary involvement
by COVID-19 based on typical CT findings (CO-RADS 5 Category Scheme). Please correlate with RT-
PCR result for further evaluation

GGO

Consolidation in known covid patient

CO-RADS: A Categorical CT Assessment Scheme by Radiological Society of North America

CO RADS 1
 Impression: very low level of suspicion for pulmonary involvement by COVID-19 based on
either normal CT results or negative for pneumonia
 mild or severe emphysema
  perifissural nodules
 lung tumors,
 fibrosis
 interstitial pulmonary edema

CO RADS 2
 Impression: low level of suspicion for pulmonary involvement by COVID-19 based on CT findings
in the lungs typical for other infection but not typical for COVID-19 (Co-Rads Category 2)
 centrilobular ground glass densities
 tree-in-bud sign, PTB
 centrilobular nodular pattern
 lobar or segmental consolidation,

 lung cavitation
 smooth interlobular septal thickening with pleural effusion
 Examples are bronchitis, infectious bronchiolitis, bronchopneumonia, lobar pneumonia, and
pulmonary abscess

CO RADS 3
 Impression: Equivocal findings for pulmonary involvement of COVID-19 based on CT features
that can also be found in other viral pneumonias or non-infectious causes
 perihilar ground-glass opacity
 small ground glass opacities not located close to the visceral pleura
 homogenous extensive ground-glass opacity with or without sparing of some secondary
pulmonary lobules,
 ground-glass opacity together with smooth interlobular septal thickening with or without pleural
effusion in the absence of other typical CT findings.

Co Rads 3 in two patients

CO RADS 4
 Impression: high level of suspicion for pulmonary involvement by COVID-19 based on CT
findings that are typical for COVID-19 but also show some overlap with other
(viral) pneumonias.
 not in contact with the visceral pleura,
 not located strictly unilaterally in a predominant peribronchovascular distribution
 superimposed on severe diffuse preexisting pulmonary abnormalities
CO RADS 5
 Impression: very high level of suspicion for pulmonary involvement by COVID-19
based on typical CT findings

 Mandatory features
◦ ground-glass opacities with or without consolidations in lung regions close to visceral pleural
surfaces, including the fissures,
◦ multifocal bilateral consolidation and GGO
◦ vicinity to the minor or major fissure is also typical
◦ Subpleural sparing can be present.
◦
 Confirmatory patterns
◦ requires the presence of at least one confirmatory pattern early in the course of COVID-19
◦ multiple ground-glass areas, which often show (half) rounded and unsharp demarcation but
can be accompanied by sharply delineated ground-glass areas that outline the shape of
multiple adjacent secondary pulmonary lobules.
◦ crazy paving pattern, with visible intralobular lines.
◦ As the disease progresses, more consolidations occur within the areas of ground-glass
opacity
◦ reverse halo signs or ground-glass opacity with extensive subpleural consolidations and air
bronchograms
◦ Subpleural curvilinear bands or bands of ground glass with or without consolidation
 Lower lobe predominance not uniformly present in typical Covid patients
HALO SIGN (viral vs fungal infection)
 Pre-existing lung findings
Emphysema none / mild / moderate / severe

Fibrosis none / mild / moderate / severe

Findings

Classic/Probable viral pneumonia COVID-19

Predominant pattern: Ground glass and consolidation in Bilateral and Peripheral 1/3 distribution- TYPICAL
in middle to lower lung and posterior segments

Early phase- GGO (interstitial edema), 50% with rounded morphology

The CT images reveal multiple ground glass densities and multifocal consolidations diffusely scattered in both lungs.
Said densities were observed in both central and peripheral portions of the lungs, in both upper and lower lobes. Some
of the said ground glass densities exhibit rounded morphology.

Late phase (8-14 days after onset symptoms)-

GGO plus reticular densities (thickened interlobular septa),
consolidative opacities, multifocal consolidation with air bronchograms
Fibrosis (2%)
thickened pleura
Decrease in GGO
Reverse halo sign (central ground glass opacity with outer ring of consolidation)
Uncommon pleural effusion (10%)
if covid case:
Commonly reported imaging features of viral pneumonia (such as Covid-19) are present. Other processes
as influenza and organizing pneumonia as can be seen with drug toxicity and connective tissue disease,
can cause similar imaging pattern. Pls correlate with RT-PCR result for further evaluation

If non covid case/no symptoms/no travel/no exposure: residual pneumonia, interstitial lung disease

Imaging features of rounded ground glass densities and multifocal consolidations with air bronchograms are commonly reported for viral pneumonia
(such as Covid-19) are present. However, minimal pleural effusion and diffuse distribution of the ground glass densities are atypical/uncommonly reported for
viral pneumonia (such as Covid-19) . Other processes as influenza and organizing pneumonia as can be seen with drug toxicity and connective tissue disease,
can cause similar imaging pattern. Please correlate with RT-PCR result for further evaluation

Indeterminate for viral pneumonia

Does not fit Classic or Non-COVID-19 patterns or clinical context
Non-peripheral GGO
Non-rounded GGO
Atypical distribution -multifocal, diffuse, perihuiar, unilateral
Impression: absence of typical features and the imaging features noted are indeterminate and can be seen in
Covid-19, though are nonspecific and can occur w/ variety of infectious or non-infectious
processes

Atypical features (Non-COVID-19)

No GGO but with Lobar or segmental consolidation – bacterial pneumonia
Nodules - Cavitation / Tree-in-bud / Centrilobular / pulmonary nodules – PTB or necrotizing pneumonia
 Smooth interlobular thickening with pleural effusion(s)
Lymphadenopathy
Bronchial wall thickening

Impression: Imaging features are atypical or uncommonly reported for (covid-19) pneumonia. Alternative diagnosis
should be considered

Negative for pneumonia

NO GGO
No consolidation

Impression:
No chest CT findings to indicate pneumonia, however, CT can still be
negative in early stages of covid
 CT scan is not substitute for RT-PCR, consider testing as clinically
warranted if with high clinical index of suspicion

Disease Distribution
Upper
Middle Lower Random
Central 2/3
Peripheral 1/3
Bronchocentric (y/n)

Other findings

Conclusion

1. Normal Correlate with RT-PCR as CT can be normal in early infection

2. Classic/Probable COVID-19 infection

CT severity score
Mild
Pure GGO, ≤3 focal abnormalities and all ≤3 cm
Mod/Severe Pure GGO, >3 focal abnormalities or >3 cm max diameter, consolidation, architectural distortion

3. Indeterminate for COVID-19 infection

CT severity score
Mild ≤3 focal abnormalities and all ≤3 cm max diameter

Mod/Severe >3 focal abnormalities or >3 cm max diameter

4. Non-COVID-19
Correlate with RT-PCR

Codes for RIS searches: CVCT0 = Normal CVCT1 = Classic/probable CVCT2 = Indeterminate CVCT3 = Non-COVID-19 Please

consider case upload to https://bit.ly/BSTICovid19_Database