Asymptomatic COVID-19: What the Neuroradiologist Needs to Know about Pulmonary Manifestations

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FIGURE.
Pulmonary manifestations of asymptomatic COVID-19 Infection. An 83-year-old man without acute respiratory symptoms presented to our institution for CT of the cervical spine following a fall from standing. Limited evaluation of the lung apex on the cervical spine CT (upper row) demonstrated bilateral GGO (asterisk) with associated interlobular septal thickening (arrowheads, crazy paving), a typical appearance for COVID-19 infection. After consultation with the treating emergency department physician, the patient was placed on droplet precautions, a COVID-19 viral test was obtained, and CT of the chest was performed to assess the extent of disease. Bilateral peripheral GGO (middle row) and organizing pneumonia (arrow) were observed (lower row). The patient’s GeneXpert COVID-19 test subsequently had positive findings, and the patient was admitted to the medical intensive care unit for observation. This case highlights the importance of familiarity with the pulmonary manifestations of COVID-19 and current expert consensus reporting recommendations. This familiarity will ensure timely, optimal patient care in the current pandemic setting.

Adapted RSNA consensus guidelines for reporting CT findings related to COVID-19^{^a}

CT Imaging Appearance	Pulmonary CT Findings	Suggested Reporting Language
Typical	Crazy paving	“Commonly reported imaging features of (COVID-19) pneumonia are present. Other processes such as influenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern.”
	Bilateral
	Peripheral
	GGO
	Bilateral
	Peripheral
	Multifocal
	Rounded
	Organizing pneumonia

Indeterminate	No typical features and	“Imaging features can be seen with (COVID-19) pneumonia, though are nonspecific and can occur with a variety of infectious and noninfectious processes.”
	GGO
	Multifocal
	Diffuse
	Perihilar
	Unilateral
	Nonrounded

Atypical	No typical or indeterminate features and	“Imaging features are atypical or uncommonly reported for (COVID-19) pneumonia. Alternative diagnosis should be considered.”
	Isolated lobar or segmental consolidation without GGO
	Centrilobular nodules
	Cavitation
	Smooth interlobular septal thickening with pleural effusion

Negative	No CT features of pneumonia	“No CT findings present to indicate pneumonia. (Note: CT may be negative in the early stages of COVID-19.)”

↵a This table was adapted from Simpson et al.⁶ Crazy paving is rounded ground glass opacification associated with inter- and intralobular septal thickening. Organizing pneumonia is a focus of GGO with peripheral consolidation previously described as “atoll sign” or “reverse halo sign.”