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Purpose: To explore the relationship between diurnal blood pressure (BP) pattern and small vessel diseases, and cognitive impairment in stroke patients.Methods: Twenty-four hour blood pressure monitoring for every 30 minutes was performed for 415 patients with ischemic stroke in chronic stage. Patients with modified Rankin Scale >2 were excluded. Patients whose Mini Mental State Examination <24 points were diagnosed as having cognitive impairment (CI). Silent lacunae and white matter lesions (WML) on MRI were identified and multiple lacunae and/or confluent WML were estimated as extensive small vessel disease (eSVD). When the nocturnal BP decline, calculated as (daytime BP -nighttime BP) / daytime BP, was more than 1.0, patients were classified as dipper, when 0-1.0 as non-dipper and when less than 0 as riser. Patients were classified into 7 groups. A: single lacuna without CI (n=110), B: multiple lacunae without CI (n=103), C: lacunar infarct with CI (n=70), D: atherothrombotic infarction (ATB) (n=71), E: ATB with CI (n=13), F: cardio embolic infarction (CE) (n=41), G: CE with CI (n=7).Results: Average 24-hour BP values (mmHg) and nocturnal BP decline were calculated. Nocturnal BP decline in the Groups with C, E and G showed significantly lower than group A. The prevalence of riser (%) in the Groups with C, E and G showed significantly higher than group A. The prevalence of eSVD in the Groups with E showed significantly higher than group D (p=0.0011) and groups G showed significantly higher than group F (p= 0.0026). Logistic regression analysis in all patients showed that more than 75 years old (versus less than 65 years old) (OR: 4.0, p=0.0006), eSVD (OR: 23.5, p<0.0001), and non-dipper and riser (versus dipper) (OR: 5.5, p=0.0003 and OR: 16.5, p<0.0001, respectively) were independently associated with CI after adjustment 24-hour averaged systolic blood pressure.Conclusions: Extensive small vessel disease and increased night time blood pressure, especially riser, were strong predictors for cognitive impairment in ischemic stroke patient. In patients with ATB and CE, eSVD was the determinant for cognitive impairment. Nighttime blood pressure, not just daytime blood pressure, should be focused on to prevent post-stroke cognitive impairment.