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Coronavirus – What Radiologists Need to Know About the COVID-19 Pandemic!

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TL;DR

Imaging features of Novel Coronavirus (COVID-19) on CT

Bilateral peripheral basal dependent ground-glass opacities (GGOs) are the hallmark, especially early in the disease.
Consolidations can be seen in the later stages, but rare to see them without GGOs
Later stages can show crazy-paving appearance, reverse halo (atoll) sign.
Some patients can have a rounded appearance of opacities.

Following features are NOT seen, typically in the early stages:

Pleural effusions
Lymphadenopathy
Cavitation
Discrete nodules
Lobar consolidation
Tree-in-bud opacities.

Please remember this important caveat though:

I do not believe that the CT findings of COVlD-19 are pathognomonic or different from other causes of acute lung injury.
#chestrad #radtwitter #radiology
Dr. Jeffrey P. Kanne MD , Professor and Chief, Thoracic Imaging, Univesity of Wisconsin
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Typical Imaging features of for pulmonary involvement of COVID-19

Obligatory features:

  • Ground-glass opacities, with or without consolidations, in lung regions close to visceral pleural surfaces, including the fissures (subpleural sparing is allowed) AND
  • Multifocal bilateral distribution

Confirmatory patterns:

  • Ground-glass regions
    • Unsharp demarcation, (half) rounded shape.
    • Sharp demarcation, outlining the shape of multiple adjacent secondary.
    • Pulmonary lobules.
  • Crazy paving.
  • Patterns compatible with organizing pneumonia.
  • Thickened vessels within parenchymal abnormalities found in all confirmatory patterns.

Reference: CO-RADS – A categorical CT assessment scheme for patients with suspected COVID-19: definition and evaluation.

Sample cases: CT findings in patients with proven COVID-19 pneumonia

CT scan image of a patient with coronavirus pneumonia
Bilateral peripheral ground-glass opacities
CT scan in patient with coronavirus showing reverse halo (atoll) sign and ground glass opaicities.
Peripheral distribution of ground-glass opacities (red arrow) with reverse halo or atoll sign (yellow arrow)
CT scan showing ground-glass opacities in a patient with COVID-19 pneumonia
Basal predominant ground-glass opacities in a patient with COVID-19 pneumonia
CT showing patchy ground-glass opacities in a patient with  COVID-19 pneumonia.
Patchy ground-glass opacities in a patient with COVID-19 pneumonia.

More radiology cases and resources available on our telegram channel: RadioGyan Telegram channel.

Video lectures for CT imaging features of COVID-19 pneumonia

Comprehensive 3- video playlist by RSNA covering the important imaging features of coronavirus and the role of radiology. Inlcudes:

1. A review of CXR and CT Findings of COVID-19.
2. The systems for structured reporting of those findings.
3. A description of how the University of Pennsylvania Medical Center has implemented structured reporting into their system.

Dr. Joseph Owen covers major imaging features of coronavirus pneumonia in this video:

uOttawa CME hosted by Dr. Carole Dennie, President of the Canadian Thoracic Society of Radiology on COVID-19 CT chest recognition:

Radiology fighting COVID-19 – Live report from Parma, Italy – Prof. Nicola Sverzellati

Imaging Findings of CoVID-19: More Than Just Ground Glass Opacities, by Henry Guo, MD, PhD

Illustrated video by Osmosis on imaging features of SARS-CoV 2 pneumonia

https://www.youtube.com/watch?v=g9jEk_gi__g

FREE case collections for imaging of coronavirus pneumonia (includes DICOM datasets for AI)

FREE DICOM COVID-19 radiology images for Artificial Intelligence studies

Temporal distribution of CT findings in patients with COVID pneumonia:

TimelineDurationPredominant finding
Early 0-2 daysNormal CT chest
Intermediate 3-5 daysGround-glass opacities
Consolidations
Peripheral distribution of disease
Linear opacities>6 daysLinear opacities

Reference: Imaging features coronavirus

Role of radiology in the diagnosis of COVID-19 / Novel COVID-19–infected pneumonia (NCIP)

Here is what the radiology imaging societies are recommending worldwide:

The Centers for Disease Control (CDC) does not currently recommend CXR or CT to diagnose COVID-19. Viral testing remains the only specific method of diagnosis.
Generally, the findings on chest imaging in COVID-19 are not specific and overlap with other infections, including influenza, H1N1, SARS and MERS.
At this time, the STR and ASER do not recommend routine CT screening for the diagnosis of patients under investigation for COVID-19.
The current position is that there is no recommended use of CT, beyond ‘routine clinical care’.
Radiology decision support tool for COVID-19 by BTSI (Click on the image for high-resolution link)

Reporting templates for COVID-19 pneumonia


The British Society of Thoracic Imaging has issued guidelines for classifying the likelihood of coronavirus pneumonia and provided templates for reporting.

Here is a link to the guidelines: BTSI COVID-19 guidelines

Templates for reporting cases:

Chest x-ray reporting template : PDF version || Word version

CT reporting template: PDF version || Word version

Structured reporting template for #COVID19 by RSNA endorsed by the Society of Thoracic Radiology and American College of Radiology:

Structured reporting template for radiology reporting of coronavirus COVID-19 pneumonia by RSNA

CO-RADS – COvid19 Reporting and Data System

The CO-RADS classification is a standardized reporting system for patients with suspected COVID-19 infection developed for a moderate to high prevalence setting. This was developed by the Dutch Radiological Society (NVvR) and published in Radiology.

CategoryLevel Of suspicion for
pulmonary involvement
of COVID-19
Summary
CO-RADS 0Not interpretableScan technically insufficient for assigning a score
CO-RADS 1Very lowNormal or non-infectious
CO-RADS 2LowTypical for other infection but not COVID-19
CO-RADS 3Equivocal / UnsureFeatures compatible with COVID-19, but also other
diseases
CO-RADS 4HighSuspicious for COVID-19
CO-RADS 5Very HighTypical for COVID-19
CO-RADS 6ProvenRT-PCR positive for SARS-CoV-2

Reference: CO-RADS – A categorical CT assessment scheme for patients with suspected COVID-19: definition and evaluation.

The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: Fleischner Society Consensus

Summary of Recommendations for Imaging for COVID-19 (SARS-CoV-2 pneumonia) by the Fleishner Society

Main Recommendations

Imaging Recommended

  • For patients with moderate to severe features of COVID-19 regardless of COVID-19 test results.
  • For patients with COVID-19 and evidence of worsening respiratory status.
  • In a resource-constrained environment where access to CT is limited, CXR may be preferred for patients with COVID-19 unless features of respiratory worsening

Imaging NOT routinely recommended

  • As a screening test in asymptomatic individuals.
  • Patients with mild features of COVID-19 unless they are at risk for disease progression.

Additional Recommendations

  • Daily chest radiographs are NOT indicated in stable intubated patients with COVID-19
  • CT is indicated in patients with functional impairment and/or hypoxemia after recovery from COVID-19.
  • COVID-19 testing is indicated in patients incidentally found to have findings suggestive of COVID-19 on a CT scan.

Reference: The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society.

Recommendations by the Iranian Society of Radiology.

  • Single breath-hold scan without oral or IV contrast.
  • Parameters:
    • Kvp: 100-120
    • mAs: 50-100
    • Pitch: 0.8-1.5
    • Thickness: 1-3 mm

Precautions for Radiology Department Personnel

Ensuring the safety of healthcare workers and other patients is essential.

The Journal of American College of Radiology and Radiology (RSNA)journals have outlined a few recommendations for the safety of radiology personnel while managing patients with coronavirus pneumonia.

These articles are available for free download:

Preventive measures for radiology personnel: A visual abstract by JACR

Here are a few of the recommendations:

  • Portable radiographic equipment should be used to limit the transportation of patients. 
  • If a patient needs to be transported to the radiology department, he or she should wear a surgical mask during transport to and from the department.
  • Radiology equipment should be disinfected after every contact with suspected patients.
  • Implementation of standard operating procedures for radiological imaging and procedures for patients with known or suspected COVlD-19 exposure.
  • Improving capability for remote interpretations (home, other sites) in the case of staff isolation or patient surge.

How to clean ultrasound machines during the coronavirus pandemic?

Check this video by American Institute of Ultrasound in Medicine (AIUM):

Mindray Ultrasound cleaning guide:

Here are recommendations from the "SFM India Oriented Guidelines for Ultrasound Establishments During the COVID19 Pandemic"

SARSCoV2, the causative agent of COVID-19 can be present on surfaces for several days. Surfaces that come into contact with the patient (cable and transducer), as well as surfaces that are touched by the clinician (keyboard, touchscreen, trackball, handlebars, etc.), should be disinfected after each examination. High-level disinfection (HLD) is not required when using ultrasound probes on intact skin. There is no evidence that HLD offers benefits for disinfection from SARS-CoV2.

The following steps should be followed:
1. Excess ultrasound gel on the transducer should be wiped off with a soft cloth after each examination. The gel can harbor a lot of germs and its presence prevents adequate disinfection.
2. Transducer surfaces and cords should be wiped with an equipment vendor-approved low-level disinfectant (LLD). Commonly approved agents include 70% Alcohol, Ammonia, 10% Bleach, Clorox, standard dilute Cidex, Protex wipes, SaniCloth, PI Spray, Oxivir wipes, Mikrobac, Microzide, Lonza, Klercide 70 and Descocept wipes.
3. Equipment desktop, edges, keyboard, transducer resting stands and especially the side in close proximity to the patient should be wiped with an LLD.
4. Commercial wipes should not be reused. These should be disposed of in appropriate bins. Cloths may be laundered with standard machine-washing.
5. Transducer and cord covers are too overpriced for general use. Makeshift covers like laparoscopy camera covers are difficult to source. These are not encouraged and LLD is adequate.
6. Ultrasound machines in COVID designated centers must be used with machine covers and covers for the transducer and cable. High-level disinfectants (HLD) is recommended in areas if ultrasound has been done where AGPs were performed.

Cleaning Recommendations from Radiology Equipment Manufacturers and ultrasound organizations:

Canon Medical Systems

GE Healthcare

Hitachi Healthcare

Philips

Siemens Healthineers

Watch this webinar by RSNA on managing radiology workflow :

Radiology Preparedness for COVID-19: Radiology Scientific Expert Review Panel

Suggestions for Radiologists and radiology reporting rooms:

Social distancing is also an important measure while at the workplace. Here is a great twitter thread that discusses ways in radiologist can practice social distancing.

Posters for social distancing in Radiology departments during COVID-19 outbreak. Paste this on your reporting room door to minimize in person contact.

Social distancing message for radiology department during coronavirus  COVID19 pandemic - Phone consult
Social distancing poster for radiology department reporting rooms. Click the image to download in PDF format.

Some more resources for managing radiology department during this period:

Resources and further reading

My 2 cents: Avoid non-emergent travel. Built-up your immunity. Avoid spreading rumors on social media. Trust only authentic sources to avoid panic. Stay safe.

DISCLAIMER: The content in this blog post is compiled from publically available sources as of March 16, 2020. The information is for medical health professionals, only for reference and not a substitute for clinical judgment

4 thoughts on “Coronavirus – What Radiologists Need to Know About the COVID-19 Pandemic!”

  1. drabhib

    thank you sir. good compilations and links.

  2. Dr Salim S S

    Very nicely compiled n Informative Article sir….

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