Purpose This study investigated the interaction between neighborhood-level social determinants of health (SDOH) and neurological risk on cognitive outcomes in children treated for brain tumors (CTBT). Additionally, the impact of redlining practices on cognitive outcomes was explored. Methods A retrospective chart review of 161 CTBT aged 5-17 was conducted. Cognitive outcomes were measured using standardized neuropsychological assessments, and SDOH were assessed using the Childhood Opportunity Index (COI) and redlining data. The Neurological Predictor Scale (NPS) measured treatment-related neurological risk. Results Compared to those in moderate and high-opportunity neighborhoods, children living in low-opportunity neighborhoods exhibited lower intellectual functioning (IF) (F[2,154]=17.7, p < .01, η ² = .19), processing speed (PS) ( F[2,89] = 4.41, p = .015, η ² = .09), perceptual reasoning (PR) (F[2,64] = 3.60, p = .03, η ² = .10), and verbal reasoning (VR) ( F[2,90] = 10.09, p < .01, η ² = .18) scores. COI levels moderated the association between NPS and IF ( F [2,174] = .038, p = .013), with a negative effect of NPS on IF in high-opportunity neighborhoods ( t = -3.82, p < .01). Children from neighborhoods less affected by redlining had better IF performance, U = 94.50, Z = -2.30, p = .021. Conclusions This study highlights the role of neurological risk and neighborhood-level SODH in cognitive outcomes in CTBT. These findings underscore the need for targeted interventions and policies aimed at mitigating the effects of systemic inequities. Future research should explore early interventions to support cognitive development in survivors from communities with less resources.