ACR TI-RADS Reference

ACR TI-RADS Reference Guide

TI-RADS Scoring System

Composition

Cystic or almost completely cystic: 0 pts
Spongiform: 0 pts
Mixed cystic and solid: 1 pt
Solid or almost completely solid: 2 pts

Echogenicity

Anechoic: 0 pts
Isoechoic or hyperechoic: 1 pt
Hypoechoic: 2 pts
Very hypoechoic: 3 pts

Shape

Wider-than-tall: 0 pts
Taller-than-wide: 3 pts

Margin

Smooth: 0 pts
Ill-defined: 0 pts
Lobulated or irregular: 2 pts
Extrathyroidal extension: 3 pts

Echogenic Foci

None or large comet-tail artifact: 0 pts
Macrocalcifications: 1 pt
Peripheral (rim) calcifications: 2 pts
Punctate echogenic foci: 3 pts

TI-RADS Categories

TR1: Benign (0 points)
TR2: Not Suspicious (1–2 points)
TR3: Mildly Suspicious (3 points)
TR4: Moderately Suspicious (4–6 points)
TR5: Highly Suspicious (≥7 points)

FNA and Follow-Up Recommendations

TI-RADS Category	Size Threshold (cm)	FNA Recommendation	Follow-Up Ultrasound
TR1	Any size	No FNA	No follow-up
TR2	Any size	No FNA	Optional follow-up if ≥2.5 cm
TR3	≥2.5	Consider FNA	Follow-up if ≥1.5 cm (1, 3, 5 yrs)
TR4	≥1.5	FNA	Follow-up if 1.0–1.4 cm (1, 2, 5 yrs)
TR5	≥1.0	FNA	Follow-up if 0.5–0.9 cm (1, 3, 5 yrs)