DIABETES/METABOLISM RESEARCH AND REVIEWS REVIEW ARTICLE Diabetes Metab Res Rev 2004; 20: 268–287. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/dmrr.490 Stroke in patients with diabetes mellitus Boris N. Mankovsky 1 * Dan Ziegler 2 1 Institute of Endocrinology, Kiev, Ukraine 2 German Diabetes Research Institute, Leibniz Institute at the Heinrich Heine University, D¨ usseldorf, Germany *Correspondence to: Dr Boris N. Mankovsky, Institute of Endocrinology, Vyshgorodskaya st., 69, Kiev, 04114, Ukraine. E-mail: mankovsk@uprotel.net.ua or mankovsky1964@yahoo.com Received: 27 March 2003 Revised: 11 December 2003 Accepted: 10 January 2004 Summary The article’s objective is to review the key advances in the scientific literature related to the association of stroke with diabetes mellitus and to summarize the current approaches to stroke prevention in diabetic patients. The key findings from the literature regarding stroke incidence in patients with diabetes, specific and nonspecific risk factors of stroke in the diabetic population, such as arterial hypertension, dyslipidemia, hyperglycemia, diabetes duration, diabetic complications, insulin resistance/hyperinsulinemia, course and outcome of stroke in subjects with diabetes and/or hyperglycemia, and the peculiarities of type, site and size of stroke in diabetic patients are discussed. The results of recent clinical trials aimed at correcting hyperglycemia, hypertension, and dyslipidemia, to prevent stroke in people with diabetes, are reviewed. The medical database Medline along with original articles from peer-reviewed journals were used for analysis. There is convincing evidence suggesting that diabetes mellitus represents a strong independent risk factor of stroke. The contribution of hyperglycemia to increased stroke risk is not proven. Data suggest an association of the full cluster of the insulin resistance syndrome and stroke. Diabetes is a risk factor mainly for ischemic stroke, while its association with hemorrhagic stroke remains controversial. Hyperglycemia is common in stroke patients, but it is not known whether it independently influences the course and outcome of stroke or merely reflects stroke severity and location. Aggressive control of arterial hypertension and dyslipidemia allows to decrease the risk of stroke in diabetic patients substantially, while the importance of glucose control for stroke prevention remains unproven. Copyright  2004 John Wiley & Sons, Ltd. Keywords diabetes mellitus; stroke; cerebral ischemia; hyperglycemia; insulin resistance; stroke prevention Epidemiology of stroke in patients with diabetes Stroke is the third leading cause of death in Western society affecting more than 600 000 persons per year in the United States [1,2]. Many epidemiolog- ical studies have convincingly shown that diabetes is one of the leading risk factors for stroke. Population risk of stroke attributable to diabetes (propor- tion of cases which potentially could be prevented by eliminating diabetes) was 18% in men and 22% in women [3]. In the Atherosclerosis Risk in Communities Study (ARIS), the risk attributable to diabetes was 21% [4]. Recently, in the US national sample of people older than 65 years, it was found that the incidence of ischemic stroke was 126.2 per 1000 person-years, which was higher than the incidence of all other diabetes-related complications but ischemic heart disease [5]. Stroke was the leading cause of mortality after malignancy in the prospective study of elderly diabetic patients [6]. Fifteen Copyright  2004 John Wiley & Sons, Ltd.