Precision medicine for cerebral Haemorrhage: Integrating Neuromarkers, Therapeutics, and recovery pathways

• Cerebral haemorrhage is a severe form of acute brain injury. • Neuromarkers are transforming diagnosis, risk stratification, treatment selection, and recovery assessment. • CT and MRI-based radiological signatures are essential for precision ICH medicine. • Emerging neuroprotective therapies and neuromodulation-based rehabilitation are guided by biomarkers. • Integrative prognostic models combine clinical, molecular, and imaging biomarkers. • Multi-omics approaches provide insights into genetic, transcriptomic, proteomic, and epigenomic landscapes. • Precision medicine in cerebral haemorrhage relies on biomarker-guided interventions and personalized recovery pathways. Intracerebral hemorrhage (ICH) is one of the most devastating and disabling forms of stroke, and its outcome is predetermined not only by the volume and location of the hematoma but also by the development of secondary injury cascades, including disruption of the blood–brain barrier, neuroinflammation, oxidative stress, iron-mediated toxicity, and disintegration of the network. Multimodal neuromarkers, including structural and vascular imaging biomarkers, circulating injury and inflammatory biomarkers, and genetic and multi-omics risk stratifiers, are redefining risk assessment, biological phenotyping, and targeted therapy in all phases of hyperacute, subacute, and recovery stages of ICH. Nevertheless, translational maturity differs significantly. Clinically actionable metrics, that is, imaging-derived metrics and hemostatic parameters, are workflow-integrated and geographically local, but most molecular, mechanistic, and computational biomarkers are investigation-oriented and often add to but do not directly aid bedside decision-making. This review presents the biomarker picture as a series of stages of clinical decision-making to hyperacute stabilization, secondary injury modulation, neurorecovery optimization, and recurrence prevention. We critically evaluated the evidence hierarchy, gaps in external validation, assay standardization issues, and clinical implementation barriers that have restricted therapeutic success in ICH. The combination of multimodal neuromarkers in a decision-oriented pathway to precision enables us to map the way to apply biological understanding to outcome-altering and patient-specific care.