Background: Hemangioma is the most common benign tumor of the spine. Most patients are asymptomatic, but some lesions can become aggressive, leading to spinal compression. Here, we reviewed the natural history and treatment of aggressive hemangiomas in asymptomatic patients. Methods: An electronic review of the literature was performed regarding the diagnosis/treatment modalities for asymptomatic aggressive hemangiomas of the spine utilizing the Medline (PubMed) and Google Scholar databases. Results: We selected four articles describing the diagnosis/management of four cases of aggressive, asymptomatic hemangiomas in patients averaging 11.25 ± 2.36 years of age. Three of the four patients were females, and all were followed an average of 36.5 ± 25 months. Notably, two of four patients required emergency surgery. Conclusion: There is a paucity of the literature regarding the diagnosis and optimal therapeutic management of aggressive hemangiomas in asymptomatic patients, half of whom may present with acute neurological deterioration warranting emergency surgery.