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Introduction This study explored the clinical value and application of ultrasound contrast imaging technology in the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) TR4 benign and malignant thyroid nodules. Methods We retrospectively analyzed data from the medical records of 40 patients who met the inclusion criteria between January 2020 and December 2023. Each patient was evaluated using the ACR TI-RADS classification and contrast-enhanced ultrasound (CEUS). The agreement between pathological outcomes and ultrasound indicators and the diagnostic value and significance of each parameter were assessed. Results The diameters did not differ between benign and malignant nodules (P = 0.324). Ring enhancement was closely associated with benign thyroid nodules, with a negative predictive value of 100%. Homogeneous enhancement and enhancement intensity showed good diagnostic value for pathological results, with an area under the curve (AUC) > 0.8. This parameter showed a high diagnostic value for serial and parallel combinations of homogeneous enhancement and enhancement intensity, with a sensitivity of 77.8% and specificity of 85.7% for the serial combination and 100% and 71.4%, respectively. for the parallel combination. Conclusion Among ACR TI-RADS TR4 nodules, diameter 1.0–1.5 cm was not significantly correlated with a benign or malignant nature. Nodules featuring ring enhancement with ring-enhancing features should be considered benign. Similarly, nodules showing no, homogeneous, or high enhancement with clear borders on CEUS imaging may be benign. However, nodules with uneven low enhancement or unclear borders may be malignant. Therefore, uneven and low enhancement on CEUS imaging may have a high diagnostic value for malignant nodules. Moreover, the combination of these features may have even higher specificity.