Extratemporal epilepsy is typically more common in pediatric epilepsy surgery candidates as compared to adults, with developmental anomalies the most common pathologic entity in this population. Developmental cortical anomalies can also be found in adults though they less commonly present in adulthood. With improvements in the invasive and non-invasive technology available for the localization of neocortical abnormalities, (e.g.), neuroimaging, extratemporal resections for epilepsy have become a more viable option for children with intractable seizures. In general, though, good surgical outcomes are lessened in the absence of a structural MR imaging abnormality and the decision for surgery is based on the functional data alone. This is becoming less true since with the latest generations of scanners and software with the use of differing techniques, it is uncommon to find no abnormality on the anatomic imaging. MR imaging in young infants though still has a lower yield for dysplastic lesions because incomplete myelin maturation can be confusing as to migrational and cortical anomalies. When anatomical imaging fails to identify a lesion, the use of functional imaging, (e.g.) PET, and invasive monitoring techniques may provide the additional information necessary to proceed with a resective or disconnection type procedure. The best overall results in patients with extratemporal lobe epilepsy, similar to the temporal lobe resections, are when the focus is single, identifiable, and resectable due to its remoteness from eloquent tissue. In patients with unilateral multilobar foci, consideration can still be given to a combined resection, such as a frontotemporal, or a parieto-occipito-temporal resection, if the seizures can be adequately localized.

In general, the principles for extratemporal resections are virtually the same as for other resective epilepsy operations. Aggressive resection and, at times, the utilization of multiple subpial transection techniques may increase success in both lesional and non-lesional cases. The overall outcome is improved in extratemporal cases when the frontal lobe is involved compared to parieto-occipital lobes. The frontal lobes present as reasonable surgical targets individually and aggressive resection of supplementary motor areas of either frontal lobe in children is possible with little long-term neurologic risk. The plasticity in young children is such that normal or near normal function is frequent even after interventions into and around the motor strip. Patients and families must be aware of the immediate postoperative effect of supplementary motor area resection where there is often a dense contralateral hemiplegia and potentially an aphasia when the resection is performed in the dominant hemisphere. These deficits frequently have proven to be temporary with excellent recovery occurring within 6 to 9 months, though these effects still present a terrifying experience for all concerned. When there is a resection involving the precentral gyrus and the motor strip, there are most often residual deficits that are permanent despite an overall excellent recovery. These include loss of fine motor movement of the hand and foot drop requiring a brace at the foot and ankle.

Parietal and occipital region surgeries are more difficult because defining eloquent areas are more difficult and seizure free rates are less. An aggressive approach in these instances may lead to deficits with variable effects. While major sensory deficits are often tolerated, visual field cuts usually have little recovery and are often difficult to adapt to completely. Overall, the results of extratemporal surgery are less satisfactory than that of a single focus (e.g., medial temporal lobe resections), because the seizure-free rates range 40-60%. Frontal lobe resections tend to do the best, while the parietal, occipital, and Rolandic areas have a notably less chance of success for a seizure-free state.