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Introduction Vertebral hemangiomas are common vascular malformations affecting 10–12% of the population, often asymptomatic but occasionally aggressive, causing spinal canal infiltration and fractures. Surgical treatment carries risks due to high vascularity and blood loss. Image-guided percutaneous methods like ethanol sclerotherapy and vertebroplasty offer minimally invasive alternatives but may not adequately address epidural components. Direct epidural ethanol injection can achieve immediate decompression.Aim of Study This study evaluates the safety and effectiveness of staged, image-guided direct epidural ethanol injection for treating aggressive vertebral hemangiomas (AVHs) with extensive epidural involvement, assessing clinical outcomes and complications.Method In this retrospective study (2017–2025), 25 AVH patients across three centers were analyzed. Fourteen patients received direct epidural ethanol injections following CT/MRI imaging. Procedures were performed under CT-guidance and general anesthesia, including intraosseous and epidural injections, followed by vertebroplasty. Outcome measures included MRI/CT evaluation of epidural size reduction and complication rates over 3–12 months.Abstract A338 Figure 1Results Of 25 patients, 14 underwent direct epidural injections (30 injections total). Patients (6 women, 8 men; mean age 50) presented with myelopathy, back pain, or neurological deficits. Two major complications occurred, both resolving without severe sequelae. Thirteen patients experienced complete symptom resolution, and most showed ≥75% reduction of the epidural component.Conclusion Direct epidural ethanol injection is a safe, effective alternative for managing AVHs with epidural involvement, offering rapid decompression and reducing the need for invasive surgery. Combined with vertebroplasty, it strengthens vertebral stability with minimal complications.Conflict of Interest No