In classroom, scientific contents are increasingly communicated through visual forms of representations. Students' learning outcomes rely on their ability to read and understand pictorial information. Understanding pictorial information in biology requires cognitive effort and can be challenging to students. Yet evidence-based knowledge about students' visual reading strategies during the process of understanding pictorial information is pending. Therefore, 42 students at the age of 14-15 were asked to think aloud while trying to understand visual representations of the blood circulatory system and the patellar reflex. A category system was developed differentiating 16 categories of cognitive activities. A Principal Component Analysis revealed two underlying patterns of activities that can be interpreted as visual reading strategies: 1. Inferences predominated by using a problem-solving schema; 2. Inferences predominated by recall of prior content knowledge. Each pattern consists of a specific set of cognitive activities that reflect selection, organisation and integration of pictorial information as well as different levels of expertise. The results give detailed insights into cognitive activities of students who were required to understand the pictorial information of complex organ systems. They provide an evidence-based foundation to derive instructional aids that can promote students pictorial-information-based learning on different levels of expertise.