INTRODUCTION The two-week wait (2WW) referral guideline for suspected central nervous system (CNS) tumours was implemented more than a decade ago to facilitate early cancer diagnosis with the aim of improving tumour survival rates. Short-term studies have shown poor compliance and low detection rates of the guideline. This study aimed to provide a decade analysis of referral patterns, and compliance and detection rates of the guideline. METHODS All patients referred via the 2WW pathway for suspected CNS tumour to the Newcastle Department of Neurosurgery from 1st January 2002 to 31st December 2011 were retrospectively identified from the local cancer registry. Data from referral letters, case notes, radiographic images and final outcomes were recorded. Trends in waiting time, time to diagnosis, compliance and detection rate of the guideline in identifying CNS tumours were analysed. RESULTS Over the last decade, there were no significant changes in trends in waiting time, time to diagnosis and compliance and detection rates of the guideline. Of 85 2WW referrals, 41.2% were non-compliant and 21.2% identified CNS tumours. The detection rate was higher in referrals that complied with the guideline compared to those that did not (32.0% vs 5.2%, p < 0.05). The non-compliant referrals which identified CNS tumours consisted of patients with cognitive decline. The guideline sensitivity and specificity were 88.8% (63.9%-98.1%, 95% CI) and 49.3% (40.0%-61.6%), respectively. Most of CNS tumour diagnoses were made independent of the 2WW pathway (N = 1093, 98.4%). CONCLUSION There have not been any major changes in terms of waiting time, time to diagnosis, compliance and detection rates of the 2WW guideline during the last decade. The 2WW pathway generated very few referrals but among these, the positive detection rate was high and the addition of time-based cognitive decline onto the current guideline may further improve the detection rate.