Background <p>This study aimed to explore the predictive value of ¹⁸F-fluorodeoxyglucose positron emission tomography ([¹⁸F]FDG PET) metabolic activity in determining postoperative motor function outcomes in patients with Rolandic focal cortical dysplasia (FCD).</p> Methods <p>We conducted a retrospective analysis of 62 patients with FCD who underwent resective surgery in the Rolandic area. Of these, 15 patients underwent task-based functional magnetic resonance imaging (fMRI). Motor functional reorganization and its relationship with PET metabolism were analyzed. Patients were classified into deficit and non-deficit groups according to their postoperative motor function status. PET metabolism in the resected motor cortex was compared between the two groups, and its correlation with postoperative muscle strength was further evaluated in the deficit group.</p> Results <p>Among the 15 patients who underwent fMRI evaluation, the extent of motor reorganization was negatively correlated with PET metabolism (<i>P</i> = 0.0006). PET analysis revealed significantly higher PET metabolic <i>T</i>-values in the resected Rolandic cortex of the motor deficit group compared to the non-deficit group (<i>P</i> = 0.0004). Furthermore, within the deficit group, PET metabolic <i>T</i>-values were negatively correlated with postoperative muscle strength (<i>P</i> = 0.017). The prediction model for postoperative motor function, demonstrated strong performance in cross-validation, with an area under the curve (AUC) of 0.82, a sensitivity of 83%, and a specificity of 76%.</p> Conclusions <p>The findings underscore the critical role of preoperative [¹⁸F]FDG-PET in predicting motor outcomes following Rolandic cortex resection in epilepsy patients, highlighting its value in optimizing preoperative assessment and surgical planning.</p>