The use of surgical treatment for depressed skull fractures that are located over major venous sinuses is a matter of controversy. However, if clinical and radiological findings of sinus obliteration and related intracranial hypertension are present, surgical decompression is indicated. The authors present the case of a 38-year-old man who had a depressed skull fracture overlying the posterior one-third portion of the superior sagittal sinus. The lesion was initially treated conservatively and the patient was readmitted 1 month later with signs and symptoms of intracranial hypertension. The role of radiological investigation in the detection of venous sinus flow and indications for surgical treatment are discussed. If venous sinus flow obstruction is revealed in the presence of signs and symptoms of intracranial hypertension, surgery is indicated as the first line of treatment.