Admission chest CT findings and risk assessment for stroke-associated pneumonia.

INTRODUCTION: Stroke-associated pneumonia (SAP) is a significant cause of morbidity and mortality after stroke. Various factors, including dysphagia and stroke severity, are closely related to SAP risk; however, the contribution of the baseline pulmonary parenchymal status to this interplay is an understudied field. Herein, we evaluated the prognostic performance of admission chest computed tomography (CT) findings in predicting SAP. METHODS: We evaluated admission chest CT images, acquired as part of a COVID-19-related institutional policy, in a consecutive series of acute ischemic stroke patients. The pulmonary opacity load at baseline was quantified using automated volumetry and visual scoring algorithms. The relationship between pulmonary opacities with risk of pneumonia within 7 days of symptom onset (i.e., SAP) was evaluated by bivariate and multivariate analyses. RESULTS: Twenty-three percent of patients in our cohort (n = 100) were diagnosed with SAP. Patients with SAP were more likely to have atrial fibrillation, COPD, severe neurological deficits, and dysphagia. The visual opacity score on chest CT was significantly higher among patients who developed SAP (p = 0.014), while no such relationship was observed in terms of absolute or relative opacity volume. In multivariate analyses, admission stroke severity, presence of dysphagia and a visual opacity score of ≥ 3 (OR 6.37, 95% CI 1.61-25.16; p = 0.008) remained significantly associated with SAP risk. CONCLUSIONS: Pulmonary opacity burden, as evaluated on admission chest CT, is significantly associated with development of pneumonia within initial days of stroke. This association is independent of other well-known predisposing factors for SAP, including age, stroke severity, and presence of dysphagia.

Two in one: Overlapping CT findings of COVID-19 and underlying lung diseases.

Coronavirus disease 2019 (COVID-19) is associated with pneumonia and has various pulmonary manifestations on computed tomography (CT). Although COVID-19 pneumonia is usually seen as bilateral predominantly peripheral ground-glass opacities with or without consolidation, it can present with atypical radiological findings and resemble the imaging findings of other lung diseases. Diagnosis of COVID-19 pneumonia is much more challenging for both clinicians and radiologists in the presence of pre-existing lung disease. The imaging features of COVID-19 and underlying lung disease can overlap and obscure the findings of each other. Knowledge of the radiological findings of both diseases and possible complications, correct diagnosis, and multidisciplinary consensus play key roles in the appropriate management of diseases. In this pictorial review, the chest CT findings are presented of patients with underlying lung diseases and overlapping COVID-19 pneumonia and the various reasons for radiological lung abnormalities in these patients are discussed.

A screening study for COVID-19-associated pulmonary aspergillosis in critically ill patients during the third wave of the pandemic.

BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) has been reported as an important cause of mortality in critically ill patients with an incidence rate ranging from 5% to 35% during the first and second pandemic waves. OBJECTIVES: We aimed to evaluate the incidence, risk factors for CAPA by a screening protocol and outcome in the critically ill patients during the third wave of the pandemic. PATIENTS/METHODS: This prospective cohort study was conducted in two intensive care units (ICU) designated for patients with COVID-19 in a tertiary care university hospital between 18 November 2020 and 24 April 2021. SARS-CoV-2 PCR-positive adult patients admitted to the ICU with respiratory failure were included in the study. Serum and respiratory samples were collected periodically from ICU admission up to CAPA diagnosis, patient discharge or death. ECMM/ISHAM consensus criteria were used to diagnose and classify CAPA cases. RESULTS: A total of 302 patients were admitted to the two ICUs during the study period, and 213 were included in the study. CAPA was diagnosed in 43 (20.1%) patients (12.2% probable, 7.9% possible). In regression analysis, male sex, higher SOFA scores at ICU admission, invasive mechanical ventilation and longer ICU stay were significantly associated with CAPA development. Overall ICU mortality rate was higher significantly in CAPA group compared to those with no CAPA (67.4% vs 29.4%, p < .001). CONCLUSIONS: One fifth of critically ill patients in COVID-19 ICUs developed CAPA, and this was associated with a high mortality.

AI-Based Quantitative CT Analysis of Temporal Changes According to Disease Severity in COVID-19 Pneumonia.

OBJECTIVE: To quantitatively evaluate computed tomography (CT) parameters of coronavirus disease 2019 (COVID-19) pneumonia an artificial intelligence (AI)-based software in different clinical severity groups during the disease course. METHODS: From March 11 to April 15, 2020, 51 patients (age, 18-84 years; 28 men) diagnosed and hospitalized with COVID-19 pneumonia with a total of 116 CT scans were enrolled in the study. Patients were divided into mild (n = 12), moderate (n = 31), and severe (n = 8) groups based on clinical severity. An AI-based quantitative CT analysis, including lung volume, opacity score, opacity volume, percentage of opacity, and mean lung density, was performed in initial and follow-up CTs obtained at different time points. Receiver operating characteristic analysis was performed to find the diagnostic ability of quantitative CT parameters for discriminating severe from nonsevere pneumonia. RESULTS: In baseline assessment, the severe group had significantly higher opacity score, opacity volume, higher percentage of opacity, and higher mean lung density than the moderate group (all P ≤ 0.001). Through consecutive time points, the severe group had a significant decrease in lung volume (P = 0.006), a significant increase in total opacity score (P = 0.003), and percentage of opacity (P = 0.007). A significant increase in total opacity score was also observed for the mild group (P = 0.011). Residual opacities were observed in all groups. The involvement of more than 4 lobes (sensitivity, 100%; specificity, 65.26%), total opacity score greater than 4 (sensitivity, 100%; specificity, 64.21), total opacity volume greater than 337.4 mL (sensitivity, 80.95%; specificity, 84.21%), percentage of opacity greater than 11% (sensitivity, 80.95%; specificity, 88.42%), total high opacity volume greater than 10.5 mL (sensitivity, 95.24%; specificity, 66.32%), percentage of high opacity greater than 0.8% (sensitivity, 85.71%; specificity, 80.00%) and mean lung density HU greater than -705 HU (sensitivity, 57.14%; specificity, 90.53%) were related to severe pneumonia. CONCLUSIONS: An AI-based quantitative CT analysis is an objective tool in demonstrating disease severity and can also assist the clinician in follow-up by providing information about the disease course and prognosis according to different clinical severity groups.

A COVID-19 first evaluation clinic at a university hospital in Turkey.

BACKGROUND: We aimed to analyze the usefulness of such a reserved area for the admission of the patients' symptoms suggesting COVID-19 and compare the demographic and clinical characteristics of the patients with COVID-19 and without COVID-19 who were admitted to C1 during the first month of the COVID-19 outbreak in our hospital. METHODS: A new area was set up in Hacettepe University Adult Hospital to limit the contact of COVID-19 suspicious patients with other patients, which was named as COVID-19 First Evaluation Outpatient Clinic (C1). C1 had eight isolation rooms and two sampling rooms for SARS-CoV-2 polymerase-chain-reaction (PCR). All rooms were negative-pressurized. Patients who had symptoms that were compatible with COVID-19 were referred to C1 from pretriage areas. All staff received training for the appropriate use of personal protective equipment and were visited daily by the Infection Prevention and Control team. RESULTS: One hundred and ninety-eight (29.4%) of 673 patients who were admitted to C1were diagnosed with COVID-19 between March 20, 2020, and April 19, 2020. SARS-CoV-2 PCR was positive in 142 out of 673 patients. Chest computerized tomography (CT) was performed in 421 patients and COVID-19 was diagnosed in 56 of them based on CT findings despite negative PCR. Four hundred and ninety-three patients were tested for other viral and bacterial infections with multiplex real-time reverse-transcriptase PCR (RTPCR). Blood tests that included complete blood count, renal and liver functions, d-dimer levels, ferritin, C- reactive protein, and procalcitonin were performed in 593 patients. Only one out of 44 healthcare workers who worked at C1 was infected by SARS-CoV-2. DISCUSSION: Early diagnosis of infected patients and ensuring adequate isolation are very important to control the spread of COVID-19. The purpose of setting up the COVID-19 first evaluation outpatient clinic was to prevent the overcrowding of ER due to mild or moderate infections, ensure appropriate distancing and isolation, and enable emergency services to serve for real emergencies. A wellplanned outpatient care area and teamwork including internal medicine, microbiology, and radiology specialists under the supervision of infectious diseases specialists allowed adequate management of the mild-to-moderate patients with suspicion of COVID-19.

COVID-19 pneumonia: the great radiological mimicker.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread worldwide since December 2019. Although the reference diagnostic test is a real-time reverse transcription-polymerase chain reaction (RT-PCR), chest-computed tomography (CT) has been frequently used in diagnosis because of the low sensitivity rates of RT-PCR. CT findings of COVID-19 are well described in the literature and include predominantly peripheral, bilateral ground-glass opacities (GGOs), combination of GGOs with consolidations, and/or septal thickening creating a "crazy-paving" pattern. Longitudinal changes of typical CT findings and less reported findings (air bronchograms, CT halo sign, and reverse halo sign) may mimic a wide range of lung pathologies radiologically. Moreover, accompanying and underlying lung abnormalities may interfere with the CT findings of COVID-19 pneumonia. The diseases that COVID-19 pneumonia may mimic can be broadly classified as infectious or non-infectious diseases (pulmonary edema, hemorrhage, neoplasms, organizing pneumonia, pulmonary alveolar proteinosis, sarcoidosis, pulmonary infarction, interstitial lung diseases, and aspiration pneumonia). We summarize the imaging findings of COVID-19 and the aforementioned lung pathologies that COVID-19 pneumonia may mimic. We also discuss the features that may aid in the differential diagnosis, as the disease continues to spread and will be one of our main differential diagnoses some time more.

Visual and software-based quantitative chest CT assessment of COVID-19: correlation with clinical findings.

PURPOSE: The aim of this study was to evaluate visual and software-based quantitative assessment of parenchymal changes and normal lung parenchyma in patients with coronavirus disease 2019 (COVID-19) pneumonia. The secondary aim of the study was to compare the radiologic findings with clinical and laboratory data. METHODS: Patients with COVID-19 who underwent chest computed tomography (CT) between March 11, 2020 and April 15, 2020 were retrospectively evaluated. Clinical and laboratory findings of patients with abnormal findings on chest CT and PCR-evidence of COVID-19 infection were recorded. Visual quantitative assessment score (VQAS) was performed according to the extent of lung opacities. Software-based quantitative assessment of the normal lung parenchyma percentage (SQNLP) was automatically quantified by a deep learning software. The presence of consolidation and crazy paving pattern (CPP) was also recorded. Statistical analyses were performed to evaluate the correlation between quantitative radiologic assessments, and clinical and laboratory findings, as well as to determine the predictive utility of radiologic findings for estimating severe pneumonia and admission to intensive care unit (ICU). RESULTS: A total of 90 patients were enrolled. Both VQAS and SQNLP were significantly correlated with multiple clinical parameters. While VQAS >8.5 (sensitivity, 84.2%; specificity, 80.3%) and SQNLP <82.45% (sensitivity, 83.1%; specificity, 84.2%) were related to severe pneumonia, VQAS >9.5 (sensitivity, 93.3%; specificity, 86.5%) and SQNLP <81.1% (sensitivity, 86.5%; specificity, 86.7%) were predictive of ICU admission. Both consolidation and CPP were more commonly seen in patients with severe pneumonia than patients with nonsevere pneumonia (P = 0.197 for consolidation; P < 0.001 for CPP). Moreover, the presence of CPP showed high specificity (97.2%) for severe pneumonia. CONCLUSION: Both SQNLP and VQAS were significantly related to the clinical findings, highlighting their clinical utility in predicting severe pneumonia, ICU admission, length of hospital stay, and management of the disease. On the other hand, presence of CPP has high specificity for severe COVID-19 pneumonia.

Lung and kidney perfusion deficits diagnosed by dual-energy computed tomography in patients with COVID-19-related systemic microangiopathy.

OBJECTIVES: There is increasing evidence that thrombotic events occur in patients with coronavirus disease (COVID-19). We evaluated lung and kidney perfusion abnormalities in patients with COVID-19 by dual-energy computed tomography (DECT) and investigated the role of perfusion abnormalities on disease severity as a sign of microvascular obstruction. METHODS: Thirty-one patients with COVID-19 who underwent pulmonary DECT angiography and were suspected of having pulmonary thromboembolism were included. Pulmonary and kidney images were reviewed. Patient characteristics and laboratory findings were compared between those with and without lung perfusion deficits (PDs). RESULTS: DECT images showed PDs in eight patients (25.8%), which were not overlapping with areas of ground-glass opacity or consolidation. Among these patients, two had pulmonary thromboembolism confirmed by CT angiography. Patients with PDs had a longer hospital stay (p = 0.14), higher intensive care unit admission rates (p = 0.02), and more severe disease (p = 0.01). In the PD group, serum ferritin, aspartate aminotransferase, fibrinogen, D-dimer, C-reactive protein, and troponin levels were significantly higher, whereas albumin level was lower (p < 0.05). D-dimer levels ≥ 0.485 µg/L predicted PD with 100% specificity and 87% sensitivity. Renal iodine maps showed heterogeneous enhancement consistent with perfusion abnormalities in 13 patients (50%) with lower sodium levels (p = 0.03). CONCLUSIONS: We found that a large proportion of patients with mild-to-moderate COVID-19 had PDs in their lungs and kidneys, which may be suggestive of the presence of systemic microangiopathy with micro-thrombosis. These findings help in understanding the physiology of hypoxemia and may have implications in the management of patients with COVID-19, such as early indications of thromboprophylaxis or anticoagulants and optimizing oxygenation strategies. KEY POINTS: • Pulmonary perfusion abnormalities in COVID-19 patients, associated with disease severity, can be detected by pulmonary DECT. • A cutoff value of 0.485 µg/L for D-dimer plasma levels predicted lung perfusion deficits with 100% specificity and 87% sensitivity (AUROC, 0.957). • Perfusion abnormalities in the kidney are suggestive of a subclinical systemic microvascular obstruction in these patients.