Circadian Blood Pressure Pattern and Microvascular and Macrovascular Cerebral Imaging Burden

Background: Nocturnal blood pressure (BP) dipping patterns have been associated with cerebrovascular disease, but the differential impact of non-dipping versus reverse dipping on white matter hyperintensity (WMH) burden and intracranial arterial calcification (IAC) remains unclear. Methods: This retrospective study included 376 patients who underwent 24 h ambulatory BP monitoring, brain MRI, and cranial CT. Patients were classified as dipper (≥10% SBP decline, n = 148), non-dipper (0–10%, n = 156), or reverse dipper (<0%, n = 72). WMH was assessed using the Fazekas scale (0–3) and analyzed with ordinal logistic regression. IAC was scored as present/absent. Multivariable models adjusted for age, sex, hypertension, diabetes, chronic kidney disease (CKD), and coronary artery disease (CAD). Results: Reverse dippers had significantly higher Fazekas grades (OR 2.26; 95% CI 1.13–4.56; p = 0.022) and IAC prevalence (OR 8.03; 95% CI 2.42–29.18; p = 0.001) compared to dippers. Non-dippers showed no association with Fazekas (OR 0.78; 0.45–1.36; p = 0.386) but were independently associated with IAC (OR 3.75; 1.43–10.76; p = 0.010). A significant dose–response trend was observed for IAC (OR 2.89 per category; 1.60–5.47; p = 0.001) but not for Fazekas grade (OR 1.35; 0.97–1.90; p = 0.078). Age, diabetes, and CAD were also independent predictors of IAC, while female sex was protective. Conclusions: Reverse dipping was associated with both higher WMH burden and IAC, whereas non-dipping was associated mainly with IAC. These findings suggest that nocturnal BP phenotypes may be differentially associated with cerebral microvascular and macrovascular imaging markers. Further prospective studies are needed to confirm these observations.