| Summary: | Vertebral hemangiomas are common benign tumors that are mostly asymptomatic and are discovered incidentally. Only 0.9–1.2% of all vertebral hemangiomas, termed aggressive vertebral hemangiomas, expand to cause pain and neural compression. We present an extremely rare case of a 49-year-old woman who had an aggressive vertebral hemangioma of the thoracic spine that caused rapidly progressive myelopathy with remarkable irregular extraosseous bone proliferation, which mimicked a malignant vertebral tumor. In this case, despite the lesion's hostile appearance during imaging, the pathological diagnosis was benign and symptom-based surgical treatment with posterior decompression and stabilization provided good clinical outcomes during the postoperative 18 months follow-up period. In this case, despite the use of standard imaging modalities (radiograph, CT, and MRI), making a preoperative imaging diagnosis of an aggressive vertebral hemangioma was difficult, and although aggressive vertebral hemangiomas with atypical radiological features are rare, they should be considered as a differential diagnosis.
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