Cardiovascular toxicity of neuro-oncologic therapies: toward a cardio-neuro-oncology framework for risk stratification, surveillance, and management

Background Patients with primary and metastatic central nervous system (CNS) tumors are increasingly treated with multimodal strategies that combine surgery, radiotherapy, alkylating chemotherapy, antiangiogenic therapy, molecularly targeted agents, selected immunotherapy, and device-based approaches. This progress has reshaped neuro-oncology and revealed a clinically important gap in contemporary cardio-oncology practice. Historically, cardio-oncology frameworks have focused on anthracyclines, HER2-directed therapies, immune checkpoint inhibitors, tyrosine kinase inhibitors, proteasome inhibitors, and thoracic radiotherapy. The cardiovascular risk profile of neuro-oncologic therapy has received comparatively less attention, although patients with CNS tumors have distinctive and overlapping risks, including intracranial disease, seizures, neurosurgery, corticosteroid exposure, immobility, thrombosis, intracranial bleeding, and delayed radiation-associated cerebrovascular disease. Main body This narrative review discusses cardiovascular complications associated with contemporary neuro-oncologic therapies, including temozolomide and other alkylating regimens, PCV, bevacizumab and other anti-VEGF strategies used mainly in recurrent or later-line disease, BRAF/MEK inhibitors, newer IDH1/2 inhibitors, immune checkpoint inhibitors, cranial radiotherapy, and tumor treating fields (TTFields). TTFields are not presented as a source of established direct cardiovascular toxicity; their cardio-oncology relevance is limited mainly to potential interactions with active implanted electronic devices, such as pacemakers or implantable cardioverter-defibrillators. Major toxicity phenotypes include hypertension, proteinuria and renal-vascular injury, left ventricular dysfunction, heart failure, QT prolongation, arrhythmias, arterial and venous thromboembolism, systemic and intracranial bleeding, very rare but serious posterior reversible encephalopathy syndrome, and delayed cerebrovascular disease. Short conclusion We propose a practical cardio-neuro-oncology framework that links baseline assessment, risk stratification, therapy-specific surveillance, early toxicity management, multidisciplinary decisions, and survivorship care. This framework is intended to support earlier recognition of cardiovascular complications, reduce unnecessary interruptions of effective anticancer therapy, and improve safety. The proposed risk categories are expert extrapolations from general cardio-oncology guidance and require validation in neuro-oncology cohorts.