Mannitol is standard treatment for suspected elevated intracranial pressure (ICP), but it has been implicated in undesirable reductions in mean arterial blood pressure. Researchers performed a meta-analysis of five unblinded randomized trials that compared equiosmolar doses of mannitol and hypertonic saline in a combined total of 112 adult patients with 184 quantitatively documented episodes of elevated ICP. None of the five trials individually identified statistically significant differences between the two agents. Combining data from the five trials resulted in slight superiority of hypertonic saline over mannitol (relative risk for ICP reduction, 1.16). The difference in magnitude of ICP reduction with the two agents was not clinically significant. Comment: This small meta-analysis of unblinded studies of patients with mixed etiologies of elevated intracranial pressure does not provide sufficient evidence to change therapy from mannitol to hypertonic saline.