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Hydrogen internal combustion engines (H2ICE) offer a cost-effective solution to decarbonize transport by combining a lower carbon intensity fuel with mature and established internal combustion engine technology. While vehicles running with hydrogen have been demonstrated over the years, this fuel's physical and chemical properties require modifications and upgrades on the vehicle from an engine and system-level perspective. In addition, market-specific regulatory and economic factors can also constrain the realization of optimal hydrogen powertrain architectures. Therefore, this paper reviews the impact of hydrogen use on combustion, injection, air management, and after-treatment systems, indicating the different strategies used to enable effective H2ICE strategies from an efficiency, cost, and safety standpoint.