BACKGROUND Vertebral hemangioma is usually a benign and asymptomatic tumor of blood vessels, but can be aggressive (symptomatic) with expansion, pain, and spinal cord compression. The aim of this study was to review the effects of radiotherapy, surgery, and other treatment approaches in patients with aggressive vertebral hemangioma. MATERIAL AND METHODS Retrospective clinical review included 20 patients who underwent radiotherapy as their first-line treatment for aggressive vertebral hemangioma with mild or slowly developing neurological deficit. External radiation was divided into 20-25 fractions with a total dose of 40-50 Gy. Minimum clinical follow-up after treatment was 20 months. RESULTS The 20 patients included eight men and 12 women (mean age, 46.6 years), with aggressive vertebral hemangioma located in the cervical, thoracic, and lumbar vertebrae in four, 14, and two patients, respectively. Following radiotherapy treatment, 65.0% of patients (13/20) were symptom-free, without recurrence or malignant transformation at the time of last clinical follow-up (average, 75.2 months). Due to minor post-radiation vertebral re-ossification, two of the 13 patients who were initially symptom-free after radiotherapy requested percutaneous vertebroplasty. A further seven patients required surgery after radiotherapy, due to increasing neurological deficit in three patients, and persistent neurological deficit in four patients. At the last follow-up (average, 63.6 months), six patients were symptom-free, and one patient still had slight residual symptoms. CONCLUSIONS Radiotherapy was a safe and effective treatment choice for aggressive vertebral hemangioma, but in case with severe spinal cord compression and neurological deficit, surgical intervention was required.