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In contemporary neurosurgery advanced imaging and visualization technologies are routinely used for precise guidance, orientation and localization. Image-guided navigation systems provide orientation to the neurosurgeon and assist in the localization of brain lesions and vital structures. When put to use in the operating room, images and visualizations take on an active role that calls for conceptual clarification. Image-guided systems such as those employed in neurosurgery remind us that there is an action dimension to images that falls outside the purview of established image-theoretical considerations, which tend to conceive images in representational terms. This article contributes to the ongoing attempts to think images beyond the representational framework. It does this by elaborating on the status and role of images used for navigation purposes in neurosurgical settings. The argument is that, when put to use as surgical tools, the agency of images plays out on two different levels: first, in the way that images and visualizations enable a leap beyond the human scale, and second, in the way that visual intermediaries, in the surgical setting, take on a guiding role.