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Vertebral hemangioma (VH) is one of the most common benign spinal tumors and can be aggressive in some cases. While most aggressive VHs have typical radiographic features, including vertical striations, a honeycomb appearance, and/or a “polka-dot sign” in computed tomography (CT) scans, cases with atypical features might complicate diagnosis. This study aimed to determine the range and frequency of these atypical features.In this retrospective study, to identify the typical and atypical features of aggressive VH, pretreatment CT and magnetic resonance imaging (MRI) were reviewed retrospectively by 1 radiologist and 1 orthopaedic surgeon. Percutaneous biopsies were performed to confirm the VH in atypical cases.A total of 95 patients with aggressive VHs were treated in our hospital from January 2005 to December 2017. Thirty-four (36%) of the lesions showed at least 1 atypical radiographic feature: 16 patients (17%) had a vertebral compression fracture, 11 patients (12%) had expansive and/or osteolytic bone destruction without a honeycomb appearance and/or “polka-dot sign”, 11 patients (12%) had obvious epidural osseous compression of the spinal cord, 12 patients (13%) had involvement of >1 segment, 9 patients (10%) had a VH centered in the pedicle and/or lamina, and 8 patients (8%) had atypical MRI signals. Forty-three patients underwent percutaneous biopsies, which had an accuracy of 86%.Based on radiographic analysis, aggressive VH can be classified as typical or atypical. More than one-third of aggressive VH lesions may have at least 1 atypical feature. CT-guided biopsies are indicated for these atypical cases.