Ischemic stroke represents the third mortality cause after cardiac diseases and tumors and the relationship between diabetes and stroke incidence is still unclear. Several studies (Framingham, Copenhagen Stroke Study, Northern Sweden MONICA, NHANES) showed a higher prevalence, recurrence rate and worse prognosis of stroke in diabetic subjects. As for cerebral ischemia pathogenesis small vessel disease of deep perforating arterioles plays a crucial role although the higher cerebrovascular risk is also related to the additional risk factors and the characteristic atherogenic diabetic profile. Significant appears the pathogenetic role of acute hyperglycemia as a direct neuronal damage mediator and negative prognostic marker. On the basis of epidemiological data, cerebrovascular risk prevention in diabetic subjects consists of secondary prevention strategies regarding glycemic control, vascular protection by ramipril and perindopril, statins and antiplatelet drugs like acetylsalicylic acid and clopidogrel as shown by randomized trials (UKPDS, DCCT, HOPE, PROGRESS, 4S, WOSCOPS, CARE, LIPID, CAPRIE, etc.).