Hyperglycemia is a common problem in the diabetic patient after an acute stroke. Maintaining therapeutic blood glucose levels in diabetics during extreme physiologic stress can present extreme challenges. Reasonably tight, yet therapeutic, control of glycemia in the diabetic stroke patient must be a priority. This article evaluates strategies for lowering glycemia to improve neurologic outcome in acute stroke patients. It reviews the literature of the epidemiology, describes the pathophysiologic process, discusses the debate over the glycemic target goal, and gives algorithms for glucose control methods for acute care. © 2009 Elsevier Inc. All rights reserved.