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Continuous hypertonic saline for hemispheric ischemic infarcts has been routinely used in neurocritical centers for the management of malignant cerebral edema. However, the data supporting its use are extremely limited. We present a systematic literature review that highlights five studies (one randomized control trial and four retrospective cohort) where the effects of continuous hypertonic saline were studied in patients with acute ischemic infarcts. Collectively, there is a lack of substantial evidence supporting its use. Also, this review emphasizes significant study flaws that make the conclusions largely nongeneralizable. Although the reported studies demonstrate improvement in control of intracranial pressure, there are no significant differences in neurological or functional outcomes or overall mortality.