Background Spontaneous intracerebral hemorrhage (sICH) is a severe stroke with high mortality and poor outcomes. Hematoma expansion critically affects prognosis, necessitating early intervention. Tranexamic acid (TXA), an antifibrinolytic, has an uncertain role in sICH. Aim This meta-analysis synthesizes evidence from randomized controlled trials (RCTs) to evaluate TXA’s efficacy and safety in sICH. Methods Comprehensive searches of PubMed, Scopus, Web of Science, and Cochrane Library identified RCTs comparing intravenous TXA to placebo in sICH, focusing on hematoma expansion. Data on functional outcomes, mortality, thromboembolic events, and quality of life were extracted. Cochrane RoB2 assessed bias; RevMan 5.4 analyzed data using fixed-effects models and subgroup analyses by time window and patient subgroups. Results Eight RCTs (2,974 patients) were included. TXA significantly reduced 24-hour hematoma volume (MD = -1.17 mL, 95% CI = -1.97 to -0.36), particularly when administered within 8 hours (MD = -1.71 mL, 95% CI = -2.68 to -0.74). However, odds of expansion, functional outcomes, 90-day mortality, thromboembolic events, and quality of life were similar between groups. Conclusion TXA reduces hematoma expansion in sICH, especially within 8 hours, without increasing thromboembolic risks. Despite this, it does not significantly improve functional outcomes, mortality, or quality of life. Current evidence does not support routine TXA use in sICH; further research is needed.